ModifiedUnitedHealthcarePolicy 2026 P 1177-11

Pa Notification Keveyis Ormalvi

UnitedHealthcare prior authorization/notification program governing coverage of dichlorphenamide (Keveyis and Ormalvi) for treatment of primary hyperkalemic periodic paralysis, primary hypokalemic periodic paralysis, and related variants; includes initial and reauthorization criteria, authorization durations, and notes on exclusions and automated approvals.

Policy Summary

PayerUnitedHealthcare

PolicyPa Notification Keveyis Ormalvi

Policy CodePolicy 2026 P 1177-11

Change TypeMODIFIED

Effective DateMay 1, 2026

Next Review Date

Key ActionPrior authorization/notification is required; initial authorizations granted for 12 months when diagnosis criteria met. Reauthorizations granted for 12 months when documentation of positive clinical response provided.

SourceLink

POLICY UPDATE CHANGES

Effective date set to 5/1/2026 and program entry noted as 2026 P 1177-11.

Updated initial authorization duration to 12 months (change noted in 2/2025).

Added generic dichlorphenamide and Ormalvi to the program (2/2025).

Added coverage exclusion statement for brand Keveyis and Ormalvi (2/2025).

Annual reviews from 2016–2026 noted; 2/2026 annual review updated references with no coverage criteria changes.

2Covered indications (named)

12 moInitial auth duration

12 moReauth duration

brands excludedBrand exclusion note

Coverage Summary

UnitedHealthcare prior authorization/notification program for dichlorphenamide (Keveyis, Ormalvi) covering treatment of primary hyperkalemic periodic paralysis, primary hypokalemic periodic paralysis, and related variants. The program requires members to meet the coverage criteria for authorization; initial authorizations are issued for 12 months and reauthorizations for 12 months. Brand products (Keveyis and Ormalvi) are typically excluded from coverage per plan specifics. Reference Policy Number 2026 P 1177-11, Effective Date 5/1/2026.

Key coverage facts

Policy number2026 P 1177-11

Effective date2026-05-01

Last review2026-02-01

Initial authorization duration12 months

Reauthorization duration12 months

Coverage stanceCovered with criteria (prior authorization/notification required)

Brand exclusion noteKeveyis (brand) and Ormalvi are typically excluded from coverage; refer to plan specifics for exclusion/tried-failed requirements.

Initial Therapy Criteria

Initial Authorization

Approved when ONE of the following diagnoses is present:

ANY of the following

Diagnosis of primary hyperkalemic periodic paralysis or related variant
Diagnosis of primary hypokalemic periodic paralysis or related variant

Continuation (Reauthorization) Criteria

Reauthorization (Continuation Therapy)

Approved when ALL of the following are met:

ALL of the following

Documentation of positive clinical response

Provider Actions & Requirements

Prior Authorization

Prior authorization / notification required

Prior authorization/notification is required; initial authorizations are granted for 12 months when diagnosis criteria are met. Reauthorizations are granted for 12 months when documentation of positive clinical response is provided.

Initial auth = 12 months
Reauth = 12 months

Documentation Required

Document clinical response for reauthorization

Providers must submit documentation of positive clinical response to support reauthorization.

Acceptable evidence: chart notes, prior medication history

Applicable Codes

Relevant diagnosis codes (ICD-10)ICD-10

No codes listed

Clinical Evidence & Definitions

Evidence and review history: Annual P&T approvals recorded 2016–2026. Product references and package inserts were updated through July 2025 per the listed Keveyis and Ormalvi package inserts. P&T change-control notes document annual reviews and specific program updates across those years.

Definitions note: The term Related variants is not explicitly defined in the policy and refers to clinical variants of primary hyperkalemic or hypokalemic periodic paralysis.

Background

Background: Keveyis and Ormalvi (dichlorphenamide) are oral carbonic anhydrase inhibitors indicated for the treatment of primary hyperkalemic periodic paralysis, primary hypokalemic periodic paralysis, and related variants. Members must meet the stated coverage criteria for authorization.

The program requires prior authorization/notification; initial approvals are issued for 12 months when diagnosis criteria are met. Reauthorization requires documentation of a positive clinical response and is issued for 12 months.

The policy notes that brand Keveyis and Ormalvi are typically excluded from coverage and tried/failed criteria may apply—refer to member-specific benefit plan details and state mandates. UnitedHealthcare may also approve initial or reauthorization based solely on prior claim/medication history, diagnosis codes (ICD-10), and/or claim logic; supply limits may be enforced.

Revision History

2016-02annual_review

P&T approval / annual review (new program entry noted in 2/2016).

2017-02annual_review

Annual review (no changes to coverage criteria).

2018-02annual_review

Annual review (no changes to coverage criteria).

Policy Summary

PayerUnitedHealthcare

PolicyPa Notification Keveyis Ormalvi

Policy CodePolicy 2026 P 1177-11

Change TypeMODIFIED

Effective DateMay 1, 2026

Next Review Date

SourceLink

On This Page

Billing Rule

Supply limits and plan exclusions may apply

Supply limits may be enforced and member-specific benefit plan coverage or state mandates may alter coverage. Brand Keveyis and Ormalvi are typically excluded — refer to plan specifics for exclusion and any tried/failed requirements.

Documentation Required

Automated approval allowance

UnitedHealthcare may approve initial and reauthorization based solely on previous claim/medication history, diagnosis codes (ICD-10) and/or claim logic per program automation.

Automated approvals may use ICD-10 and claim history

2019-02annual_review

Annual review; updated references and background.

2020-02annual_review

Annual review; updated references (no changes to coverage criteria).

2021-02annual_review

Annual review (no changes to coverage criteria).

2022-02annual_review

Annual review (no changes to coverage criteria).

2023-02annual_review

Annual review; added state mandate noted with no changes to coverage criteria.

2024-02annual_review

Annual review; updated reference (no changes to coverage criteria).

2025-02material_change

Material changes: updated initial authorization to 12 months; added generic dichlorphenamide and Ormalvi to the program; added coverage exclusion statement that brand Keveyis and Ormalvi are typically excluded (tried/failed criteria may apply).

2026-02annual_review

Annual review; updated references with no changes to coverage criteria.

2026-05-01effective_dateLatest

Effective date set for the program (Program Number 2026 P 1177-11).