UnitedHealthcare non-solid dosage Prior Auth

Coverage Criteria for Non‑Solid Oral & Suppository Forms

Section A: Single-criterion approval for listed products

Covered when ONE of the following is met (applies to multiple listed products in section A):

Section A - general approval: Patient is unable to ingest a solid dosage form (e.g. an oral tablet or capsule) due to age OR oral/motor difficulties OR dysphagia

Applies as one pathway for products listed in section A (see chunk 3).

Feeding tube criterion

Alternate qualifying criterion:

Feeding tube pathway: Patient utilizes a feeding tube for medication administration

Alternate pathway to approval for products under section A (chunk 4).

Section B: Zegerid suspension

Zegerid suspension approval requires BOTH of the following:

Zegerid criterion 1: Patient is unable to ingest a solid dosage form (e.g. an oral tablet or capsule) due to age OR oral/motor difficulties OR dysphagia OR patient utilizes a feeding tube for medication administration

Chunk 5-6

Zegerid criterion 2: History of trial and failure, intolerance or contraindication to BOTH Nexium suspension (esomeprazole) AND lansoprazole orally disintegrating tablets (generic Prevacid SoluTabs)

Chunk 7

Section C: Eprontia

Eprontia approval requires EITHER both criteria in path 1 OR feeding tube use:

Eprontia path 1: Patient is unable to ingest a solid dosage form (e.g. an oral tablet or capsule) due to age OR oral/motor difficulties OR dysphagia AND history of trial and failure, intolerance or contraindication to topiramate sprinkles (Topamax Sprinkle)

Chunks 8-9

Eprontia path 2: Patient utilizes a feeding tube for medication administration

Chunk 10

Section D: Valsartan oral solution

Valsartan oral solution approval requires BOTH of the following:

Valsartan criterion 1: Patient is unable to ingest a solid dosage form (e.g. an oral tablet or capsule) due to age OR oral/motor difficulties OR dysphagia OR utilizes feeding tube for medication administration

Chunk 11

Valsartan criterion 2: History of trial and failure, intolerance or contraindication to one of: enalapril oral solution (generic Epaned) OR Qbrelis (lisinopril) oral solution

Chunk 12

Section E: Xelstrym

Xelstrym approval requires BOTH of the following (complex multi-step requirement):

Xelstrym criterion 1: Patient is unable to ingest a solid dosage form (e.g. an oral tablet or capsule) due to age OR oral/motor difficulties OR dysphagia OR utilizes feeding tube for medication administration

Chunk 13

Xelstrym criterion 2: History of trial and failure, intolerance or contraindication to BOTH: (a) amphetamine/dextroamphetamine extended‑release (generic Adderall XR) opened and sprinkled on soft food (e.g., applesauce) AND (b) one of: methylphenidate extended‑release capsules (generic Metadate CD, generic Ritalin LA) opened and sprinkled on soft food OR dexmethylphenidate extended‑release (generic Focalin XR) opened and sprinkled on soft food

Chunk 14

Section F: Sympazan

Sympazan approval requires BOTH of the following:

Sympazan criterion 1: Patient is unable to ingest a solid dosage form (e.g. an oral tablet or capsule) due to age OR oral/motor difficulties OR dysphagia OR utilizes feeding tube for medication administration

Chunk 15

Sympazan criterion 2: History of trial and failure or intolerance to clobazam oral suspension (generic Onfi)

Chunk 16

Section G: Imkeldi

Imkeldi approval requires BOTH of the following:

Imkeldi criterion 1: Patient is less than 19 years of age

Chunk 17

Imkeldi criterion 2: Patient is unable to achieve desired dose by dissolving imatinib 100 mg or 400 mg tablets in water or apple juice

Chunk 18

Section H: Vyscoxa

Vyscoxa approval requires BOTH of the following:

Vyscoxa criterion 1: Patient is unable to ingest a solid dosage form (e.g. an oral tablet or capsule) due to age OR oral/motor difficulties OR dysphagia OR utilizes feeding tube for medication administration

Chunk 19

Vyscoxa criterion 2: Patient is unable to achieve desired dose by opening celecoxib capsules and adding to applesauce

Chunk 20

Initial approval criteria for non-solid formulations

Covered when BOTH of the following are met for a requested non-solid formulation:

Primary criteria: (1) Patient is unable to ingest a solid dosage form (e.g., oral tablet or capsule) due to age OR oral/motor difficulties OR dysphagia OR use of feeding tube; AND (2) Patient is unable to achieve desired dose by manipulating available solid formulations (examples given: dissolving imatinib tablets; opening celecoxib capsules and adding to applesauce; using lamotrigine chewable tablet).

Specific examples provided for Vyscoxa, Subvenite, and imatinib-related products.

Claims for certain products will auto-process for specified younger age groups and therefore may not require prior authorization. Specifically, claims for patients under age 6 will process automatically for a list of products including Alkindi Sprinkle, Arbli, Brynovin, Carospir, chlorpromazine oral solution, Epaned, Fleqsuvy, Flolipid, Indocin, Inzirqo, Jylamvo, Khindivi, Lopressor oral solution, Meloxicam suspension, Naprosyn suspension, Nexium suspension, Norliqva, Ozobax DS, Prevacid SoluTab, Prograf Granules, Qbrelis, Raldesy TM, Simvastatin oral suspension (Flopid authorized generic), Sotylize, Subvenite, Tezruly, Tirosint-Sol, Vyscoxa, Xatmep and Xromi. In addition, claims for patients under age 8 will auto-process for Pradaxa oral pellets and claims for patients under age 19 will auto-process for Imkeldi. These automated processing rules affect workflow for prescribers and pharmacies because requests meeting the age-based conditions may bypass prior authorization checks.

Some products are identified in the document as typically excluded from coverage. Examples called out in the references/history include Feqsuvy, Indocin Suspension, Indocin Suppositories and Nexium Suspension. The references also note product list changes (e.g., Brynovin, Subvenite and Vyscoxa additions), and the policy states that brand‑only products may be typically excluded. Review member-specific benefit plan coverage and the references section when evaluating coverage for these products.

Approvals may be subject to programmatic supply limits and can be influenced by prior claim or medication history and submitted diagnosis codes. UnitedHealthcare may approve initial or reauthorization requests based solely on previous claim/medication history, ICD-10 diagnosis coding, and claim logic; use of automated approval and reapproval processes varies by program or therapeutic class. Absence of required documentation or conflicts with member plan coverage or state/federal mandates may result in non-approval.

Initial Therapy — Product-Specific Criteria

Product-specific initial therapy criteria

Initial approval criteria for specific products

Vyscoxa initial: (1) Patient cannot ingest solid dosage form (age, oral/motor difficulties, dysphagia, or feeding tube) AND (2) Patient is unable to achieve desired dose by opening celecoxib capsules and adding to applesauce.

Authorization will be issued for 12 months if criteria met.

Subvenite initial: (1) Patient cannot ingest solid dosage form (age, oral/motor difficulties, dysphagia, or feeding tube) AND (2) Patient is unable to achieve desired dose with lamotrigine chewable tablet.

Authorization will be issued for 12 months if criteria met.

Imatinib manipulation example: Patient is unable to achieve desired dose by dissolving imatinib 100 mg or 400 mg tablets in water or apple juice.

Used as an example requirement for approval of non-solid formulation alternatives.

Reauthorization / Continuation Rules

Reauthorization

Reauthorization/continuation rules

Reauthorization: Authorization will be issued for 12 months when initial criteria continue to be met.

Applies to listed products when criteria satisfied.

Step Therapy and Prior Trial Requirements

Product / scenario	Required documentation of trial/failure/intolerance/contraindication
Zegerid suspension	Document history of trial and failure, intolerance, or contraindication to BOTH: (1) Nexium suspension (esomeprazole) AND (2) lansoprazole orally disintegrating tablets (Prevacid SoluTabs, generic)
Eprontia (oral suspension)	Document history of trial and failure, intolerance, or contraindication to topiramate sprinkles (Topamax Sprinkle)
Valsartan oral solution	Document history of trial and failure, intolerance, or contraindication to one of: (a) enalapril oral solution (generic Epaned) OR (b) Qbrelis (lisinopril) oral solution
Xelstrym	Document history of trial and failure, intolerance, or contraindication to BOTH: (a) amphetamine/dextroamphetamine ER (Adderall XR) opened and sprinkled on soft food AND (b) one of: methylphenidate ER capsules (e.g., Metadate CD, Ritalin LA) opened and sprinkled on soft food OR dexmethylphenidate ER (Focalin XR) opened and sprinkled on soft food
Sympazan	Document history of trial and failure or intolerance to clobazam oral suspension (generic Onfi)

Historical example	Description (historical step requirement)
Valsartan oral solution (historical update)	Policy history notes Valsartan oral solution was updated to require stepping through enalapril oral solution (brand/generic Epaned) or Qbrelis (lisinopril) prior to approval in a prior reference update.

What Providers Must Do

Prior Authorization

Prior Authorization Required

Prior authorization is required for the non‑solid oral and suppository products listed in the Coverage Criteria unless the claim auto‑processes by age per the Background (examples: many products auto‑process for patients <6, Pradaxa pellets <8, Imkeldi <19). Approvals are issued when the applicable clinical criteria below are met. Authorization periods are generally 12 months when criteria require documentation of inability to ingest solids or use of a feeding tube.

Prior authorization required for listed non‑solid oral and suppository products except where claims auto‑process by age (see Background).
Approvals issued for 12 months when criteria met (many product-specific criteria specify 12‑month authorization).

Denial Risk

Denial Risks and Automated Approval Note

Requests may be denied when the prescriber-submitted documentation does not meet the policy criteria (for example: no evidence the patient is unable to ingest solid oral dosage forms, no trial/ failure documentation when required, or feeding tube use not documented). Coverage is also subject to the member's specific benefit plan, state mandates, product availability, and other utilization management programs (automated approval processes vary by program/therapeutic class). Supply limits may apply.

Definitions

Unable to ingest a solid dosage form — defined

DefinitionUnable to ingest a solid dosage form (e.g. an oral tablet or capsule) due to age, oral/motor difficulties, or dysphagia.

Examples - ageYoung pediatric patients who cannot swallow tablets or capsules.

Examples - oral/motor difficultiesPatients with neuromuscular or developmental conditions impairing chewing or swallowing function.

Examples - dysphagiaPatients with diagnosed swallowing disorders limiting safe oral intake of solid dosage forms.

Feeding tube use

DefinitionUse of a feeding tube for medication administration is an alternate qualifying condition for approval.

Background

This policy defines UnitedHealthcare coverage criteria for non-solid oral and suppository dosage forms when a patient is unable to ingest solid oral dosage forms. It explains qualifying conditions such as age, oral/motor difficulties, dysphagia, or use of a feeding tube, and describes product‑specific requirements (for example, when prior trial/failure of alternative formulations is required). Note that automated processing rules and supply limits may apply and that member benefit plans, state mandates, and other utilization management programs can also affect coverage decisions.

Revision History and Policy Updates

2025-06added

Imkeldi, Inzirqo, Raldesy, and Xromi were added to the policy criteria.

2026-02addedLatest

Subvenite and Vyscoxa were added to the policy criteria.