CurrentUnitedHealthcarePolicy CSINDO0123.06

Qalsody (tofersen) — Medical Benefit Drug Policy (Indiana Community Plan)

Medical benefit drug policy for Qalsody (tofersen) that applies only to UnitedHealthcare Community Plan members in the state of Indiana. It references InterQual criteria for clinical coverage determinations.

Policy Summary

PayerUnitedHealthcare

PolicyQalsody (tofersen) — Medical Benefit Drug Policy (Indiana Community Plan)

Policy CodePolicy CSINDO0123.06

Change TypeRoutine reviewno content changes

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionProviders must reference and satisfy the current InterQual guideline criteria for Qalsody when requesting coverage and supply documentation demonstrating that the patient meets those clinical eligibility criteria.

SourceLink

POLICY UPDATE CHANGES

Routine review performed with no content changes; previous policy version CSINDO0123.05 archived.

1Applicable state (Indiana)

J1304HCPCS code listed for tofersen

InterQualClinical criteria source referenced

Medical Necessity Criteria

Medical necessity — reference to InterQual criteria

Policy Summary

PayerUnitedHealthcare

PolicyQalsody (tofersen) — Medical Benefit Drug Policy (Indiana Community Plan)

Policy CodePolicy CSINDO0123.06

Change TypeRoutine reviewno content changes

Effective DateJun 1, 2025

Next Review DateN/A

SourceLink

On This Page

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ALL of the following

Patient meets the clinical coverage criteria as specified in the current InterQual guideline for Tofersen (Qalsody): CP: Specialty Rx Non-Oncology; Tofersen (Qalsody).
InterQual criteria contain the detailed inclusion/exclusion and any step therapy or prior authorization conditions.

Providers must reference and satisfy the current InterQual guideline criteria for Qalsody when requesting coverage; medical necessity is determined against those InterQual criteria.

Providers should supply documentation demonstrating that the patient meets the InterQual clinical eligibility criteria when submitting requests for Qalsody.

Provider Requirements and Documentation

Prior Authorization

Prior authorization and medical necessity determination

Providers must reference and satisfy the current InterQual guideline criteria for Qalsody when requesting coverage; medical necessity is determined against those InterQual criteria.

J1304

Documentation Required

Documentation requirement

Providers should supply documentation demonstrating that the patient meets the InterQual clinical eligibility criteria when submitting requests for Qalsody.

J1304

Clinical & Administrative Context

This policy addresses Qalsody (tofersen) as a specialty therapy managed under UnitedHealthcare’s Medical Benefit Drug Policy for the UnitedHealthcare Community Plan in Indiana. The policy is specific to the state of Indiana and is identified as Policy Number CSINDO0123.06 with an effective date of June 1, 2025.

UnitedHealthcare relies on a third-party clinical criteria set, InterQual, to determine medical necessity for Qalsody. Coverage decisions for Qalsody are made by evaluating whether the patient meets the current InterQual guideline for Tofersen (Qalsody): CP: Specialty Rx Non-Oncology; Tofersen (Qalsody). Providers requesting coverage must reference and document that the patient satisfies the applicable InterQual clinical eligibility criteria.

The policy lists applicable billing information for reference, including the HCPCS code J1304 (Injection; tofersen, mg). This version reflects a routine review with no content changes compared to the prior archived version (CSINDO0123.05).

OpenPayer

Qalsody (tofersen) — Medical Benefit Drug Policy (Indiana Community Plan)

Medical Necessity Criteria

Relevant Billing Codes

Provider Requirements and Documentation

Clinical & Administrative Context

Defined Terms

Policy Updates

Qalsody (tofersen) — Medical Benefit Drug Policy (Indiana Community Plan)

Medical Necessity Criteria

Relevant Billing Codes

Provider Requirements and Documentation

Clinical & Administrative Context

Defined Terms

Other Policy References

Policy Updates