UnitedHealthcare Gilotrif Prior Auth Coverage | OpenPayer

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UnitedHealthcare Gilotrif Prior Auth Coverage | OpenPayer

Initial Authorization - Metastatic NSCLC

Covered when ALL of the following are met

NSCLC initial: Diagnosis of metastatic non-small cell lung cancer (NSCLC)

Required

NSCLC qualifying subcriteria: One of: (a) Squamous disease progressing after previous platinum-based chemotherapy; (b) Tumors are positive for non-resistant epidermal growth factor receptor (EGFR) mutations

Either condition satisfies this node

Reauthorization - NSCLC

Covered when ALL of the following are met

NSCLC reauthorization: Patient does not show evidence of progressive disease while on Gilotrif therapy.

Authorization issued for 12 months

Initial Authorization - Advanced Head and Neck Cancer

Covered when ALL of the following are met

H&N initial: Diagnosis of advanced, non-nasopharyngeal head and neck cancer

Required

H&N prior therapy: Disease has progressed on or after platinum-containing chemotherapy

Required

Reauthorization - Head and Neck Cancer

Covered when ALL of the following are met

H&N reauthorization: Patient does not show evidence of progressive disease while on Gilotrif therapy.

Authorization issued for 12 months

Initial Authorization - Brain Metastases

Covered when ALL of the following are met

Brain mets initial: Diagnosis of brain metastasis due to EGFR-sensitizing mutation positive non-small cell lung cancer

Required

Reauthorization - Brain Metastases

Covered when ALL of the following are met

Brain mets reauthorization: Patient does not show evidence of progressive disease while on Gilotrif therapy.

Patients less than 19 years of age

Covered when the following is met

Pediatric: Patient is less than 19 years of age

Authorization will be issued for 12 months; prescriptions may automatically process without coverage review for members under 19

NCCN Recommended Regimens

NCCN recognition: Drug recognized by the NCCN Drugs and Biologics Compendium with a Category of Evidence and Consensus of 1, 2A, or 2B

May support coverage

Safety and efficacy of Gilotrif (afatinib) have not been established for tumors that harbor resistant EGFR mutations. This limitation of use means Gilotrif is not supported for patients whose tumor testing demonstrates EGFR resistance mutations rather than the non-resistant/EGFR-sensitizing alterations for which the drug is indicated.

Provider Actions and Authorization Notes

Prior Authorization

Prior Authorization Required for NSCLC

Prior authorization for NSCLC — provider requirements and key prior auth triggers.

Initial authorization requires diagnosis of metastatic non-small cell lung cancer (NSCLC).
Approval contingent on either: squamous disease progressing after prior platinum-based chemotherapy, or tumors positive for non-resistant EGFR mutations.
Authorization will be issued for 12 months.

Prior Authorization

Prior Authorization Required for Head and Neck Cancer

Prior authorization for head and neck cancer — provider requirements and prior auth triggers.

Initial authorization requires diagnosis of advanced, non-nasopharyngeal head and neck cancer.
Disease must have progressed on or after platinum-containing chemotherapy.
Authorization will be issued for 12 months.

Prior Authorization

Prior Authorization Required for Brain Metastases

Prior authorization for brain metastases — provider requirements and reauthorization notes.

Initial authorization requires diagnosis of brain metastasis due to EGFR-sensitizing mutation positive non-small cell lung cancer.
Authorization will be issued for 12 months.

Prior Authorization

Pediatric Prior Authorization / Automatic Processing Under Age 19

Pediatric prior authorization — requirements for members less than 19 years of age.

Gilotrif will be approved for patients less than 19 years of age when the patient is under 19.
Authorization will be issued for 12 months.
For members under age 19, the prescription will automatically process without a coverage review (subject to state mandates).

Note

Supply Limits and Automated Approvals

Supply limits / automated approval notes — supply and program variation caution.

Supply limits may be in place.
Use of automated approval and re-approval processes varies by program and/or therapeutic class.

Note

Claims-Based Approval Allowed

Claims-based approval allowance — approvals based on claims/medication history and diagnosis codes.

UnitedHealthcare may approve initial and reauthorization based solely on previous claim/medication history, diagnosis codes (ICD-10) and/or claim logic.
Automated approval and re-approval processes vary by program and/or therapeutic class; check program-specific rules.

Note

Operational Coverage Notes

Coverage operational note — processing rules, state mandates, and under-19 auto-processing.

Some states mandate coverage for off-label use or require different Compendium references; where mandates apply, they supersede this policy language.
For members under the age of 19 years, the prescription will automatically process without a coverage review unless state rules dictate otherwise.