Currentsierra health and lifePolicy 2025D0112D

Provider Administered Drugs - Preferred Products

Parameters for coverage of UnitedHealthcare preferred and non-preferred medical benefit treprostinil injection products; affects providers administering treprostinil under the medical benefit and coverage decision-makers.

Policy Summary

Payersierra health and life

PolicyProvider Administered Drugs - Preferred Products

Policy CodePolicy 2025D0112D

Change TypeRevised non-preferred product list

Effective DateJul 1, 2025

Next Review Date

Key ActionMembers new to therapy must use the UnitedHealthcare preferred product; coverage of non-preferred treprostinil requires documented intolerance/contraindication and physician attestation.

SourceLink

POLICY UPDATE CHANGES

Revised list of non-preferred medical drug products and removed specified Par Sterile Products (inactive NDCs).

Archived previous policy version 2024D0112C.

1HCPCS code listed (J3285)

4Par Sterile NDCs removed

multiplePresentations listed

Coverage Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Preferred product coverage: Coverage will be provided for the UnitedHealthcare preferred product contingent on the coverage criteria in the Diagnosis-Specific Criteria section.

Members new to therapy required to use preferred product

Non-preferred product coverage: Treatment with a specified non-preferred product is medically necessary when BOTH: (1) history of intolerance or contraindication to a UnitedHealthcare preferred product, AND (2) physician attests same intolerance/contraindication/adverse event would not be expected with the non-preferred product.

Physician attestation required

Use of a specified non-preferred product is allowed only when the Preferred Product Criteria are satisfied. Both of the following must be documented: (1) a history of intolerance or contraindication to a UnitedHealthcare preferred product, and (2) a physician attestation that the same intolerance/contraindication or adverse event would not be expected with the non-preferred product. Members new to therapy are required to trial the UnitedHealthcare preferred product unless these criteria are met.

Provider Actions and Requirements

Step Therapy

Preferred-product-first requirement

Members new to therapy are required to use the UnitedHealthcare preferred product before coverage of a non-preferred product will be considered. Coverage will be provided for the UnitedHealthcare preferred product contingent on the coverage criteria in the Diagnosis-Specific Criteria section.

Applies to members who are new to treprostinil therapy
Preferred-product-first requirement is enforced prior to authorization of non-preferred products

Denial Risk

Coverage for non-preferred products may be denied if Preferred Product Criteria are not met

Coverage for a non-preferred product may be provided only when the Preferred Product Criteria are met. Specifically, treatment with a non-preferred product is medically necessary when both: (1) there is a documented history of intolerance or contraindication to a UnitedHealthcare preferred product; and (2) the prescribing physician attests that the same intolerance, contraindication, or adverse event would not be expected to occur with the non-preferred product. If these Preferred Product Criteria are not met, coverage for the non-preferred product may be denied.

Physician attestation must state intolerance/contraindication to the preferred product and that the issue is unlikely to occur with the non-preferred product
Coverage decisions for non-preferred products require meeting both the Preferred Product Criteria and applicable Diagnosis-Specific Criteria

Background

This policy addresses selection among injectable treprostinil formulations covered under the medical benefit by distinguishing UnitedHealthcare preferred products from specified non-preferred branded or alternative presentations. Coverage decisions follow the preferred-product-first approach and are contingent on the Diagnosis-Specific Criteria; members new to therapy must use the preferred product unless they meet the Preferred Product Criteria for non-preferred use. Refer to diagnosis-specific drug policies where noted.

Definitions

UnitedHealthcare preferred medical drug products (examples)

Preferred product (examples)Treprostinil 20mg/20mL Solution for Injection (Sandoz Inc.)

Preferred product (examples)Treprostinil 100mg/20mL Solution for Injection (Sandoz Inc.)

Preferred product (examples)Treprostinil 200mg/20mL Solution for Injection (Sandoz Inc.)

UnitedHealthcare non-preferred medical drug products (examples)

Non-preferred branded productRemodulin (treprostinil) 1 mg/mL and other Remodulin concentrations (United Therapeutics Corporation)

Non-preferred generic/alternative — TevaTreprostinil 50mg/20mL, 100mg/20mL, 200mg/20mL presentations (Teva Pharmaceuticals USA)

Non-preferred generic/alternative — Dr. Reddy'sTreprostinil 20mg/20mL; 50mg/20mL; 100mg/20mL; 200mg/20mL Solution for Injection (Dr. Reddy's Laboratories, Inc.)

Initial Therapy Criteria

Initial Therapy

Initial therapy for new members

New-to-therapy requirement: Members new to therapy are required to utilize the UnitedHealthcare preferred product unless they meet Preferred Product Criteria for a non-preferred product.

Physician attestation and documented intolerance/contraindication required for non-preferred use.

Continuation Therapy Criteria

Continuation Therapy

Continuation or ongoing therapy

Ongoing therapy guidance: Coverage for ongoing therapy follows the same preferred-product-first approach and diagnosis-specific criteria; members already on therapy may be subject to policy preference requirements described.

Refer to Diagnosis-Specific Criteria and member plan.

Step	Requirement	Notes
1	Trial of UnitedHealthcare preferred product required for members new to therapy	Coverage of a non-preferred treprostinil product will be considered only when Preferred Product Criteria are met (e.g., documented intolerance or contraindication to a preferred product plus physician attestation)

Biosimilar / Alternate Presentations

Billing Rule

Preferred (Sandoz) and non‑preferred (Remodulin, Teva, Dr. Reddy’s) presentations listed

UnitedHealthcare lists specific Sandoz treprostinil presentations as preferred products and lists Remodulin and specified Teva and Dr. Reddy’s treprostinil presentations as non‑preferred alternatives; use the Preferred Product Criteria to justify non‑preferred use.

Examples of preferred products: Sandoz treprostinil 20mg/20mL, 100mg/20mL, 200mg/20mL (per policy listings)
Examples of non‑preferred products: Remodulin (various concentrations) and specified Teva and Dr. Reddy’s treprostinil presentations