UnitedHealthcare Alunbrig Prior Auth Coverage Update | OpenPayer

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UnitedHealthcare Alunbrig Prior Auth Coverage Update | OpenPayer

Prior Authorization and Provider Requirements

Prior Authorization

Prior Authorization Required — ALK-positive NSCLC

Prior authorization is required for Alunbrig for ALK-positive non-small cell lung cancer (NSCLC). Initial approval requires a documented diagnosis of NSCLC that is metastatic, recurrent, or advanced, and confirmation the tumor is anaplastic lymphoma kinase (ALK)-positive. Authorization will be issued for 12 months.

Initial authorization: diagnosis of NSCLC; disease must be metastatic, recurrent, or advanced; tumor ALK-positive.
Authorization period: 12 months.
Reauthorization: patient must show no evidence of progressive disease while on Alunbrig therapy; reauthorization issued for 12 months.

Prior Authorization

Prior Authorization Required — IMT (ALK-translocated)

Prior authorization is required for Alunbrig for inflammatory myofibroblastic tumor (IMT). Initial approval requires a diagnosis of IMT and documented presence of an ALK translocation. Authorization will be issued for 12 months.

Initial authorization: diagnosis of inflammatory myofibroblastic tumor (IMT) and presence of ALK translocation.
Authorization period: 12 months.
Reauthorization: patient must show no evidence of progressive disease while on Alunbrig therapy; reauthorization issued for 12 months.

Prior Authorization

Prior Authorization Required — Erdheim‑Chester Disease

Prior authorization is required for Alunbrig when used as targeted therapy for symptomatic Erdheim‑Chester Disease with an ALK‑fusion in relapsed or refractory disease. Initial approval requires documented symptomatic ECD used as targeted therapy for ALK‑fusion. Authorization will be issued for 12 months.

Initial authorization: symptomatic Erdheim‑Chester Disease, used as targeted therapy for ALK‑fusion, and disease is relapsed or refractory.
Authorization period: 12 months.
Reauthorization: patient must show no evidence of progressive disease while on Alunbrig therapy; reauthorization issued for 12 months.

Prior Authorization

Prior Authorization Required — CNS Metastases (ALK-positive)

Prior authorization is required for Alunbrig for central nervous system (CNS) metastases from ALK‑positive NSCLC. Initial approval requires a diagnosis of metastatic brain cancer from NSCLC and confirmation the tumor is ALK‑positive. Authorization will be issued for 12 months.

Initial authorization: diagnosis of metastatic brain cancer from NSCLC and tumor ALK‑positive.
Authorization period: 12 months.

Prior Authorization

Prior Authorization Required — ALCL (ALK-positive)

Prior authorization is required for Alunbrig for anaplastic large cell lymphoma (ALCL) when the tumor is ALK‑positive and disease is relapsed or refractory. Initial approval requires diagnosis of ALCL, ALK‑positive tumor, relapsed or refractory disease, and use as palliative intent therapy or as second‑line/subsequent therapy. Authorization will be issued for 12 months.

Initial authorization: diagnosis of anaplastic large cell lymphoma; tumor ALK‑positive; disease relapsed or refractory; used as palliative intent therapy or second‑line/subsequent therapy.
Authorization period: 12 months.

Note

Benefit Plan and Regulatory Impacts

Coverage may be impacted by member-specific benefits and applicable state or federal mandates. Some states require coverage for off‑label uses or reference alternate compendia; where such mandates apply they supersede the benefit document or notification criteria.

For members under 19 years old, the prescription may automatically process without a coverage review.
State mandates or federal requirements may override policy language or require use of different compendia.

Note

NCCN Recognition

The drug is recognized by the NCCN Drugs and Biologics Compendium with a Category of Evidence and Consensus of 1, 2A, or 2B for the cancer indications noted.

NCCN recognition: Category 1, 2A, or 2B as applicable.

Prior Authorization

Operational Approvals and Additional Clinical Rules

UnitedHealthcare may operationally approve initial and reauthorization requests based solely on prior claims/medication history, diagnosis codes (ICD‑10), and claim logic. Automated approval and re‑approval processes and any supply limits may vary by program or therapeutic class.

Approvals may be based on previous claim/medication history and diagnosis codes.
Supply limits may be applied.
Use of automated approval/reapproval processes varies by program/therapeutic class.

Step Therapy and Regimen Recognition

Step	Requirement
NCCN recognition	The drug is recognized for the cancer indication by the NCCN Drugs and Biologics Compendium with Category 1, 2A, or 2B evidence — no additional step sequence is specified in this document.