CurrentUnitedHealthcarePolicy 2024 P 1366-4

Rezurock (belumosudil) prior authorization

Defines UnitedHealthcare prior authorization requirements for Rezurock (belumosudil) for members, including initial and reauthorization criteria and duration of approval. Applies to providers requesting coverage for the drug.

Policy Summary

PayerUnitedHealthcare

PolicyRezurock (belumosudil) prior authorization

Policy CodePolicy 2024 P 1366-4

Change TypeRemoved age criteriaother administrative updates

Effective DateNov 17, 2024

Next Review Date

Key ActionSubmit prior authorization with a diagnosis of chronic graft-versus-host disease and documentation of failure of at least two lines of systemic therapy.

SourceLink

POLICY UPDATE CHANGES

Removed age criteria from the program during the 9/2024 annual review.

Added state mandate footnote during a prior annual review.

Updated references (package insert, NCCN) and annual review notes were recorded.

12 monthsinitial authorization duration

12 monthsre-authorization duration

>=2required prior systemic therapy lines failed

12+ yrslabeled age population

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Coverage Criteria for Rezurock (belumosudil)

inv-01: Initial Authorization

Covered when ALL of the following are met

Initial Authorization: Diagnosis of chronic graft-versus-host disease (chronic GVHD)

Initial Authorization: History of failure of at least two lines of systemic therapy (examples: corticosteroids, mycophenolate, tacrolimus)at least 2 prior systemic therapy failures

Authorization will be issued for 12 months

inv-02: Reauthorization

Covered when ALL of the following are met

Reauthorization: Documentation of positive clinical response to Rezurock therapypositive clinical response

Authorization will be issued for 12 months

Coverage is subject to applicable state mandates, federal regulatory requirements, and the member's specific benefit plan. UnitedHealthcare may therefore limit or modify coverage based on plan design or state law; providers should verify member benefits before requesting authorization. In addition, automated approval or re-approval processes may be used in some programs, and supply limits may apply.

Initial Therapy Criteria

inv-10: Initial Therapy

Initial coverage criteria for starting therapy

Initial: Diagnosis of chronic graft-versus-host disease (chronic GVHD)

Initial: History of failure of at least two lines of systemic therapy (examples: corticosteroids, mycophenolate, tacrolimus)>=2 failed systemic therapies

Approval for 12 months

Continuation / Reauthorization Criteria

inv-11: Continuation Therapy / Reauthorization

Reauthorization requires demonstration of continued clinical benefit.

Reauthorization: Documentation of positive clinical response to Rezurock therapypositive clinical response

Authorization issued for 12 months

Provider Actions and Documentation Requirements

Prior Authorization

Initial Authorization — documentation required

Rezurock (ruxolitinib) initial authorization requires documentation of a diagnosis of chronic graft-versus-host disease (chronic GVHD) and a history of failure of at least two prior systemic therapies. Examples of systemic therapies include corticosteroids, mycophenolate, tacrolimus, and others. Authorization will be issued for 12 months if criteria are met.

Diagnosis: chronic graft-versus-host disease (chronic GVHD) must be documented
Prior therapy: failure of >= 2 systemic therapies (e.g., corticosteroids, mycophenolate, tacrolimus)
Authorization length: 12 months for initial approval

Step Therapy

Step therapy requirement — prior failure of ≥ 2 systemic therapies

Step therapy: member must have documented failure of two or more systemic therapies before Rezurock will be approved. Provide medication names, dates of therapy, and reason for failure (lack of efficacy or intolerance).

Acceptable examples of prior systemic therapies: corticosteroids, mycophenolate, tacrolimus, others
Documentation should include dates, doses, and clinical rationale for discontinuation

Documentation Required

Reauthorization — positive response documentation

Reauthorization requires documentation of a positive clinical response to Rezurock therapy. Provide clinical notes, objective measures, or other relevant assessments demonstrating improvement.

Documentation of positive clinical response required for reauthorization
Authorization length: 12 months for reauthorization

Denial Risk

Documentation triggers for denial

Missing or incomplete documentation may lead to denial. Specifically, absence of a clear chronic GVHD diagnosis or lack of documentation showing failure of at least two prior systemic therapies are triggers for denial. Also, failure to provide evidence of positive clinical response at reauthorization may result in denial of continued coverage.

Denial triggers: no documented diagnosis of chronic GVHD
Denial triggers: insufficient documentation of ≥ 2 prior systemic therapy failures (names, dates, reasons)
Denial triggers: no evidence of positive clinical response for reauthorization

Step Therapy and Prior Treatments

Prior therapy	Failure documented?
Systemic corticosteroids (example)	Failure of at least two lines required; document prior failure
Mycophenolate (example)	Failure of at least two lines required; document prior failure
Tacrolimus (example)	Failure of at least two lines required; document prior failure
Other systemic therapies (other immunosuppressants)	Failure of at least two lines required; document prior failure

Site of Care and Operational Notes

Note

Site‑of‑care: no explicit restrictions; check state/plan mandates

The policy includes no explicit site‑of‑care restrictions; however, state mandates, federal requirements, and the member’s benefit plan may affect coverage or site‑of‑care decisions.

Background

Rezurock (belumosudil) is a kinase inhibitor indicated for the treatment of chronic graft‑versus‑host disease in patients 12 years and older. The policy requires a documented diagnosis of chronic graft‑versus‑host disease for coverage consideration and aligns authorization rules with the product's labeled age population.

Definitions

Chronic GVHD — definition and coverage requirement

DefinitionChronic graft-versus-host disease (chronic GVHD)

Coverage requirementDiagnosis of chronic graft-versus-host disease is required for Rezurock (belumosudil) coverage

Context from label/indicationProduct indicated for patients 12 years and older with chronic GVHD after failure of ≥2 lines of systemic therapy

Documentation implicationDiagnosis must be documented in the prior authorization request (diagnosis codes/medical record) to support approval

Quantity Limits and Supply

Rezurock (belumosudil) — supply / quantity considerations

Quantity/availability ruleRezurock (belumosudil) may be subject to supply limits

Program variabilitySupply limits are program- and therapeutic-class dependent and may vary by program

Approval pathwaysUnitedHealthcare may still approve initial or re-authorization based on claim/medication history or diagnosis codes despite supply limits

Provider actionProviders should verify current supply limits and member-specific program rules when requesting prior authorization