CurrentUnitedHealthcarePolicy CSPA2025D0095H

Viltepso (Viltolarsen) (for Pennsylvania Only)

UnitedHealthcare Medical Benefit Drug Policy for Viltepso (viltolarsen) applies only to Pennsylvania and describes criteria for initial and continuation coverage for treatment of Duchenne muscular dystrophy (DMD) amenable to exon 53 skipping, coding references, background, evidence, and FDA indication.

Policy Summary

PayerUnitedHealthcare

PolicyViltepso (Viltolarsen) (for Pennsylvania Only)

Policy CodePolicy CSPA2025D0095H

Change TypeRevised coverage criteria

Effective DateAug 1, 2025

Next Review Date

Key ActionIf patient previously received gene therapy for DMD, submit records documenting clinically meaningful functional decline since gene therapy to qualify.

POLICY UPDATE CHANGES

Revised coverage criteria for initial therapy to add requirement that one of the following be met: patient has not previously received gene therapy for DMD; or both prior gene therapy and documentation of clinically meaningful functional decline since gene therapy.

1Covered Indication (DMD amenable to exon 53 skipping)

12 monthsInitial Authorization Length

J1427Single Drug HCPCS Code Listed

Coverage Summary

Coverage stance: Viltepso (viltolarsen) is covered with criteria for the treatment of Duchenne muscular dystrophy (DMD) in patients with a confirmed DMD gene mutation amenable to exon 53 skipping, limited in scope to Pennsylvania only. The policy notes the FDA indication and that approval is under accelerated approval based on increased dystrophin in skeletal muscle. Effective date: August 1, 2025. Last review: August 1, 2025.

Key Policy Facts

Policy NumberCSPA2025D0095H

ScopeUnitedHealthcare Medical Benefit Drug Policy for Viltepso (viltolarsen) applies only to Pennsylvania and describes criteria for initial and continuation coverage for DMD amenable to exon 53 skipping

Coverage stanceCovered with criteria (covered_with_criteria) for DMD amenable to exon 53 skipping

Initial authorization lengthInitial authorization will be for no more than 12 months

Single drug HCPCS codeJ1427 (Injection, viltolarsen, 10 mg)