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UnitedHealthcare Retevmo Prior Auth Coverage | OpenPayer

v1.0.11

OpenPayerPolicy UpdatesPharmacy & Specialty DrugsUnitedHealthcare Retevmo Prior Auth Coverage | Ope…

CurrentUnitedHealthcarePolicy N/A

Retevmo (selpercatinib) prior authorization

Prior authorization and notification rules for coverage of Retevmo (selpercatinib) for specified indications including RET fusion-positive/RET-mutant cancers; affects prescribers and pharmacies submitting coverage requests to UnitedHealthcare.

Policy Summary

PayerUnitedHealthcare

PolicyRetevmo (selpercatinib) prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 15, 2026

Next Review DateN/A

Key ActionSubmit a prior authorization request for Retevmo unless the patient is under 19, in which case prescriptions auto-process without coverage review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization period for approved requests

Age <19members auto-processed

Cat 1/2A/2BNCCN recognition

2025 P 1320-7program id

Coverage Criteria for Retevmo (selpercatinib)

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Patients less than 19 years of age

Covered when ALL of the following are met

Pediatric automatic coverage: Patient is less than 19 years of age

Authorization issued for 12 months

Non-Small Cell Lung Cancer (NSCLC) - Initial

Covered when ALL of the following are met

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

Disease status: Disease is recurrent, advanced, or metastatic

Molecular marker: Presence of RET gene fusion-positive or RET rearrangement positive tumors

Authorization issued for 12 months

Non-Small Cell Lung Cancer (NSCLC) - Reauthorization

Reauthorization covered when ALL of the following are met

No progression: Patient does not show evidence of progressive disease while on Retevmo therapy

Authorization issued for 12 months

Thyroid cancers - Initial

Covered when ALL of the following are met (two alternative sets allowed as described)

MTC pathway: Diagnosis of medullary thyroid cancer (MTC); disease is advanced or metastatic; disease has presence of RET gene mutation; disease requires treatment with systemic therapy

Authorization issued for 12 months

Thyroid cancer fusion pathway: Diagnosis of thyroid cancer; disease is advanced or metastatic; disease is RET gene fusion-positive; disease requires systemic therapy; patient is radioactive iodine-refractory or radioactive iodine is not appropriate

Authorization issued for 12 months

Thyroid cancers - Reauthorization

Reauthorization covered when ALL of the following are met

No progression: Patient does not show evidence of progressive disease while on Retevmo therapy

Authorization issued for 12 months

Histiocytic Neoplasms - Initial

Covered when ALL of the following are met

Diagnosis list: Diagnosis of Langerhans Cell Histiocytosis, Erdheim-Chester disease, or Rosai-Dorfman disease

Use case: Used for RET fusion target as a single agent

Authorization issued for 12 months

Histiocytic Neoplasms - Reauthorization

Reauthorization covered when ALL of the following are met

No progression: Patient does not show evidence of progressive disease while on Retevmo therapy

Authorization issued for 12 months

Solid tumors with RET fusion - Initial

Covered when ALL of the following are met

Molecular marker: Presence of RET gene fusion-positive solid tumor

Disease status: Disease is recurrent, advanced, or metastatic

Authorization issued for 12 months

Solid tumors with RET fusion - Reauthorization

Reauthorization covered when ALL of the following are met

No progression: Patient does not show evidence of progressive disease while on Retevmo therapy

Authorization issued for 12 months

NCCN Recommended Regimens

Coverage acknowledgement

NCCN recognition: The drug is recognized for treatment by the NCCN Drugs and Biologics Compendium with Category of Evidence and Consensus of 1, 2A, or 2B

Some states mandate benefit coverage for off-label use of medications or require use of specific compendia. Where such state mandates apply, they supersede the language in this policy and take precedence over the criteria described here.

Initial Therapy Authorization Criteria

Initial therapy

Initial authorization criteria vary by diagnosis and generally require diagnosis, disease stage (advanced/ metastatic/ recurrent), and presence of RET alteration where specified.

General initial: Diagnosis and disease status appropriate for indication and presence of RET gene fusion/rearrangement or RET mutation as specified per indication

Authorization issued for 12 months

Reauthorization / Continuation Criteria

Reauthorization

Reauthorization is approved when patient shows no evidence of disease progression on therapy.

Continuation criterion: Patient does not show evidence of progressive disease while on Retevmo therapy

Authorization issued for 12 months

Provider Actions and Prior Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required — Prior authorization is required for Retevmo except prescriptions for members under 19 which will automatically process without a coverage review. Some states mandate coverage or use of other Compendium references; where state mandates apply, they supersede this policy and may impact coverage.

Automatic processing without coverage review for members < 19 years
State mandates may supersede this policy and alter coverage requirements

Note

Other Utilization Management Programs

Other utilization management programs and automated processes may apply. UnitedHealthcare may approve initial authorizations and reauthorizations based on previous claim or medication history, diagnosis codes (ICD-10), and/or claim logic. Supply limits may be enforced.

Automated approval/re-approval processes may be used
Approvals may be based on claims/medication history, ICD-10 codes, and claim logic
Supply limits may apply

Quantity Limits and Product Identification

Retevmo (selpercatinib) — Supply limits

Quantity limit noteSupply limits may be in place

Authorization periodApprovals are issued for 12 months when criteria are met

Automated processesUnitedHealthcare may use automated approval and re-approval processes that can affect supply handling

Definitions

RET gene fusion/rearrangement or RET mutation

DefinitionGenomic alterations in the RET proto-oncogene identified by an FDA-approved test indicating potential responsiveness to selpercatinib.

Test requirementRET fusion or RET mutation must be detected by an FDA-approved test

Relevance to indicationsRequired for indications including RET fusion-positive NSCLC, RET-mutant medullary thyroid cancer, RET fusion-positive thyroid cancer, and RET fusion-positive solid tumors

Background

Retevmo (selpercatinib) is a kinase inhibitor indicated for treatment of adult patients with locally advanced or metastatic RET fusion-positive non‑small cell lung cancer (NSCLC), adult and pediatric (≥2 years) patients with advanced or metastatic RET‑mutant medullary thyroid cancer who require systemic therapy, patients with RET fusion–positive thyroid cancer that is radioactive iodine‑refractory or for whom radioactive iodine is not appropriate, and for patients with locally advanced or metastatic solid tumors with RET fusions after progression on or when no satisfactory alternative systemic therapy exists. The National Comprehensive Cancer Network (NCCN) also recognizes single‑agent Retevmo for certain histiocytic neoplasms.

Policy Summary

PayerUnitedHealthcare

PolicyRetevmo (selpercatinib) prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 15, 2026

Next Review DateN/A

Key ActionSubmit a prior authorization request for Retevmo unless the patient is under 19, in which case prescriptions auto-process without coverage review.

SourceLink

On This Page

Coverage Criteria for Retevmo (selpercatinib)Initial Therapy Authorization Criteria Reauthorization / Continuation Criteria Provider Actions and Prior Authorization Requirements Quantity Limits and Product Identification Definitions Background