Viltepso (viltolarsen) — Medical Benefit Drug Policy (New Jersey)
Defines UnitedHealthcare coverage criteria for the medical benefit use of Viltepso (viltolarsen) for patients with Duchenne muscular dystrophy amenable to exon 53 skipping and notes restrictions on concomitant use with Duvyzat (givinostat). Applies to UnitedHealthcare standard benefit plans subject to applicable federal/state/contractual terms.
Revised coverage criteria; added criterion requiring Viltepso will not be used concomitantly with Duvyzat (givinostat).
Archived previous policy version CSNJ2025D0095M.
Coverage Criteria
The policy includes a specific exclusion: Viltepso (viltolarsen) must not be used concomitantly with Duvyzat (givinostat). Requests that indicate the drugs will be used together are subject to denial per the revised coverage criteria effective 05/01/2026.
Provider Actions and Operational Rules
Benefit plan governance
Coverage determinations for Viltepso should follow UnitedHealthcare Medical Benefit Drug Policy procedures and any applicable prior authorization requirements. Providers must verify member-specific benefit plan, federal, state, and contractual requirements before requesting coverage; in the event of a conflict, the federal, state, or contractual requirements govern. This policy is informational and does not replace plan-specific coverage rules or legal requirements.
- Follow UnitedHealthcare Medical Benefit Drug Policy prior authorization workflows where applicable
- Check member's federal, state, or contractual benefit requirements prior to submission
- Policy is informational — plan documents govern in case of conflict
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