CurrentUnitedHealthcarePolicy N/A

Xuriden (uridine triacetate) prior authorization

Defines UnitedHealthcare Pharmacy prior authorization and reauthorization criteria for Xuriden (uridine triacetate) for members; applies to clinicians and pharmacists requesting coverage. Effective 9/1/2025.

Policy Summary

PayerUnitedHealthcare

PolicyXuriden (uridine triacetate) prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionFor initial authorization, document a diagnosis of hereditary orotic aciduria; for reauthorization, provide documentation of positive clinical response (approvals issued for 12 months).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

9/1/2025policy effective date

hereditary orotic aciduriaapproved diagnosis

positive responsereauthorization requirement

12 moauthorization duration

Coverage Criteria for Xuriden (uridine triacetate)

Policy Summary

PayerUnitedHealthcare

PolicyXuriden (uridine triacetate) prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionFor initial authorization, document a diagnosis of hereditary orotic aciduria; for reauthorization, provide documentation of positive clinical response (approvals issued for 12 months).

SourceLink

On This Page

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Provider Action and Documentation Requirements

Prior Authorization

Initial Authorization Required

Initial prior authorization requires documentation of a diagnosis of hereditary orotic aciduria.

Diagnosis required: hereditary orotic aciduria

Documentation Required

Reauthorization and Documentation

Reauthorization requires documentation of a positive clinical response to Xuriden therapy. Authorizations for reauthorization will be issued for 12 months. State mandates, federal requirements, and member-specific benefit plan coverage may affect criteria.

Positive clinical response required for reauthorization
Authorization duration: 12 months

Denial Risk

Denial Triggers and Automated Approval

Requests missing the required diagnosis for initial authorization or lacking documentation of positive clinical response for reauthorization may be denied. UnitedHealthcare may also apply automated approval or re-approval based on prior claim/medication history, ICD-10 diagnosis codes, and claim logic; supply limitations or other utilization management programs may apply.

Denial triggers: missing required diagnosis for initial authorization; insufficient documentation of positive clinical response for reauthorization
Automated approvals: may be used based on prior claims/medication history, diagnosis codes, and claim logic
Note: supply limitations and other programs may apply

Program element	Description
Automated approval and re-approval	UnitedHealthcare may approve initial and reauthorization requests based solely on prior claim/medication history, diagnosis codes (ICD-10), and/or claim logic; use of automated approval and re-approval processes varies by program and therapeutic class.
Supply limitations	Supply limitations may be in place for automated approvals or standard authorizations.

OpenPayer

Xuriden (uridine triacetate) prior authorization

Coverage Criteria for Xuriden (uridine triacetate)

Initial Authorization Criteria

Reauthorization / Continuation Criteria

Provider Action and Documentation Requirements

Background

Definitions

Step Therapy / Automated Approval Logic