View claims details. Group Policy UnitedHealthcare Insurance Company 185 Asylum Street Hartford, Connecticut 06103-0450 860-702-5000 Issued To: Burbank Management Association ("Enrolling Group") Policy Number: 754054 Policy Effective Date: October 1, 2016 Policy Anniversary Date: October 1 h�b```b``�e`c`U`d@ AV�(G�#���6�U��JHs�m�z'X�j���0e9�����1�{—�Х�=;��(���(��r#δ�c�1י��Q��9,]bS&�4I�#*��G��t]�W5�Mi�0JJ�,�q�2Rŀ��w� �`9��� ^b !��AP�٬�g� ˂Au�v� ��EN ��j`�P~��BRF�� ,[9��Tx/�h��ɬ͡*3���;�`hej8�8�������9��W�����$i��'�4#���a`��H-6���m� �Vg`V���c\` �5p� � Vi A Prescription Drug List (PDL) – also called a formulary – is a list of commonly used medications, organized into cost levels, called tiers. h�bbd```b``���+A$��cf�̋�lv�* This list may not be inclusive of all available NDC’s for each drug product and is subject to change. FDA-authorized COVID-19 vaccines are covered at $0 cost-share during the national public health emergency period. Are you using social media? UnitedHealthcare Adds Shingrix Vaccine to Preventive Benefits March 22, 2018. This policy refers to the following complement inhibitor drug products: • Soliris (eculizumab) • Ultomiris (ravulizumab-cwvz) Soliris and Ultomiris are proven for the treatment of atypical hemolytic uremic syndrome (aHUS). 979 0 obj <>/Filter/FlateDecode/ID[<72493F861F1C2D40BAC8308A7129D592><439B9936F60E12448C68D54587E46307>]/Index[942 96]/Info 941 0 R/Length 156/Prev 206269/Root 943 0 R/Size 1038/Type/XRef/W[1 3 1]>>stream Note that market specific restrictions or transition-of-care benefit limitations may apply. 0 Make a premium payment. &5�"�&0 D���.�d��� f��Y]�f6�u����A��)�"�kA�y�dd������ "����s�����Y���q�t����{ �b� v��������r��-Cu��W#8̫ ��bȤ)>?4mz��:ϡnN�;�K�&N��b�5���Y`A�+���F The UnitedHealthcare name with the dimensional logo, as well as the dimensional logo alone, are both service marks of UnitedHealthcare. Sign in to Medicare Member Site. 1029 0 obj <>stream %%EOF endstream endobj 921 0 obj <. If it isn’t, you may have better coverage for rehab services. 942 0 obj <> endobj DRUG POLICY Soliris® (eculizumab) COVERAGE RATIONALE . 0 Complement Inhibitors (Soliris® & Ultomiris®) – Commercial Medical Benefit Drug Policy Last Published 02.01.2021 Effective Date: 02.01.2021 – This policy addresses the use of Soliris® (eculizumab) and Ultomiris® (ravulizumab-cwvz). Medicare Policy: Prior authorization is dependent on the member’s Medicare coverage. UnitedHealthcare will include Shingrix® vaccination as a covered preventive service benefit for adults age 50 and over beginning April 1, 2018 with network coverage at no cost share. These costs are decided by your employer or health plan. Login here! Eculizumab (Soliris®) On June 27, 2019, The U.S. Food and Drug Administration approved Eculizumab (Soliris®) for the treatment of adult patients with neuromyelitis optica spectrum disorder (NMOSD) who are anti-aquaporin-4 (AQP4) antibody positive. INSTRUCTIONS FOR USE . Register or login to your UnitedHealthcare health insurance member account. Prior Authorization Required: Yes . %%EOF h�bbd```b``��+A$7��> %PDF-1.5 %���� 1,12. Medication Name Diagnosis How Supplied National Drug Code Maximum Allowed Brand Generic Soliris eculizumab aHUS 300 mg vials 25682-0001-01 4 vials/120 ml Lost your member ID card? Complement ®Inhibitors (Soliris® & Ultomiris ) Page 1 of 10 UnitedHealthcare Value & Balance Exchange Medical Benefit Drug Policy Effective 01/01/2021 Proprietary Information of UnitedHealthcare. endstream endobj 943 0 obj <. Alexion Pharmaceuticals has reached a patent settlement with Amgen over Soliris (eculizumab), Alexion’s blockbuster antibody treatment for the blood disease paroxysmal nocturnal haemoglobinuria (PNH). If you have an AARP Medicare, UnitedHealthcare Medicare, or Group Retiree plan, sign in to: Learn about your plan coverage and benefits. Soliris is contraindicated in patients with unresolved serious Neisseria meningitidis infection, and patients who are not currently vaccinated against Neisseria meningitidis, unless the risks of delaying Soliris treatment outweigh the risks of developing a meningococcal infection. �6ADrG��`� 920 0 obj <> endobj Soliris and Ultomiris are medically necessary when all of the following criteria are met: Initial Therapy: Unauthorized use and distribution are prohibited. See what UnitedHealthcare can do for you. As used in this policy, terms such as "we" or "our" and “Company” refer to UnitedHealthcare and its current and future affiliated entities, including our parent company UnitedHealth Group. Not everyone knows the full details of their insurance policy. endstream endobj startxref This policy refers to the following complement inhibitor drug products: Soliris (eculizumab) Ultomiris (ravulizumab-cwvz) Soliris and Ultomiris are proven and medically necessary for the treatment of atypical Hemolytic Uremic Syndrome (aHUS) when all of the following criteria are met: 1,12 . SOLIRIS (eculizumab) 1 of 5 . COVERAGE Benefits may vary between groups/contracts. Substance Abuse and Mental Health Benefits vs. General Health Benefits. This Drug Policy provides assistance in interpreting UnitedHealthcare … UnitedHealthcare. "���E~���`�� ��D�r��8��&�}�6�C@$�6XDo�L�5 R�������z�A$W��&�����$�yXD��P��'��.�L�@�D����������lV��8JR������ � �,X While not all UnitedHealthcare plans include an MNRP, it is essential to know if it is part of your policy. This policy does not apply to information collected through other means such as by telephone or in person, although that information may be protected by other privacy policies. CRX-ALL-0488-20 Note: Soliris (eculizumab) has a black box warning for serious meningococcal infections. Utilization Review Policy 194A This document is confidential and proprietary to UCare. Rather than pay the provider directly, this type of supplemental insurance pays you a predetermined amount for certain expenses you incur related to your healthcare, and then you pay the remainder. 1,12 . Soliris Policy: Drug Policy (Effective 10/01/2014) 1 Proprietary information of UnitedHealthcare. We encourage you to read, share, follow us and provide commentary on Facebook®, Twitter®, Pinterest®, Instagram® and other social media The Centers for Disease Control and Prevention and state health departments are advising who can get the vaccines and when. Prescribed dose of Soliris does not exceed 900 mg for the first 4 weeks, followed by 1200 mg for the fifth dose 1 week later, then 1200 mg every 2 weeks thereafter; So are we! SOLIRIS (eculizumab) MB9938. Medicare member site. Covered Service: Yes . The agreement prevents Amgen’s biosimilar version of Soliris … 959 0 obj <>/Filter/FlateDecode/ID[<145A377B261808479B4BAB586216CA40><2C866201764382478BD34FD6BA94BD6A>]/Index[920 110]/Info 919 0 R/Length 163/Prev 210946/Root 921 0 R/Size 1030/Type/XRef/W[1 3 1]>>stream Complement Inhibitors includes the following products: • Eculizumab (Soliris ®) • Ravulizumab (Ultomiris. CLINICAL POLICY Eculizumab . Copyright © 201 4 UnitedHealthcare. This policy does not apply to health plans or member categories that do not have pharmacy benefits, nor does it apply to Medicare. In its comments about the new policy, UnitedHealthcare said that, if the lab does not have such a contract, claims submitted for non-patient diagnostic laboratory tests, or claims for which a hospital is acting as a reference laboratory, will be denied for failure to comply with the new policy if the hospital submits bills under its facility participation agreement. • New Reimbursement Policy: Pediatric and Neonatal Critical and Intensive Care Services • Previously Announced Changes Delayed for UnitedHealthcare of the River Valley – Reimbursement Policies That Apply to Commercial Claims Subject to the River Valley Entities Supplement • Policy Revision and Renaming of Codes Not Intended for Find resources about vaccine availability for your area, or learn more about COVID-19 vaccines and your plan benefits by signing in. Additional Information: Must be prescribed by nephrology, hematology, or transplant specialists with prior authorization through Navitus . Explore employer, individual & family, Medicare-Medicaid health insurance plans from UnitedHealthcare. UnitedHealthcare has a history of limiting HIV drug costs, including offering cash incentives to patients who opt for low-priced regimens. UnitedHealthcare Anesthesia Policy Update. POLICY STATEMENT Eculizumab(Soliris) is medically necessary when the criteria above has been met. POLICY: ®Soliris (eculizumab injection, for intravenous use –Alexion) EFFECTIVE DATE: 1/1/2020 LAST REVISION DATE: 5/27/2020 COVERAGE CRITERIA FOR: UCare Medicaid and Exchange Plans Only (PMAP, Connect, MSC+, MnCare, all Individual and Family Plans) policy as well as the process by which NDC claims are billed. Under the Soliris REMS, prescribers must enroll in the program (Alexion Pharmaceuticals, 2019a). Life- Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable physician administered infused drug benefit. UnitedHealthcare is a registered service mark of UnitedHealthcare, Inc. 1037 0 obj <>stream This policy supports medical necessity review of eculizumab (Soliris ®) and ravulizumab (Ultomiris™). TM) Coverage Policy . Get answers to your questions here. This policy refers to the following complement inhibitor drug products: Soliris (eculizumab) Ultomiris (ravulizumab-cwvz) Soliris and Ultomiris are proven for the treatment of atypical Hemolytic Uremic Syndrome (aHUS). For questions concerning the technical %PDF-1.5 %���� Have questions about your UnitedHealthcare member identification (ID) card? Soliris and Ultomiris are medically necessary when all of the following criteria are met: Initial Therapy: View and print your ID card. h�b```b``Ng`c`�8� Ȁ ��@Q�FF�/;�,�bH[��"�y���l��P������Q�^Jx��|dXj�P��e��‰_���7 endstream endobj startxref Initial Therapy: Е��`�� (^a0���`VC�� ��`)F!w�� �k��C �``zn�U�X,���짿���3G��+?�ְ-� �h۴��.�=�5���ۤ��8��ŬRe�Ȁ�y��t.VƲ�lF,Pgll�4i��gA������e�>����@q�6G H�10�l��cl0 �_|[ UnitedHealthcare modifies telehealth reimbursement policy for 2021 One of the nation’s largest insurers is changing (www.uhcprovider.com) its telehealth reimbursement policy this year. ***Note: This Medical Policy is complex and technical. Page 2 of 6 4. It offers limited benefits and is designed to supplement your regular health insurance. Have health insurance through your employer or have an individual plan? Group Policy UnitedHealthcare Insurance Company UnitedHealthcare Insurance Company 185 Asylum Street Hartford, Connecticut 06103-0450 This Policy is entered into by and between UnitedHealthcare Insurance Companyand the "Enrolling Group," as described in Exhibit 1. March 2019 ~ UnitedHealthcare (UHC) has issued Anesthesia Policy updates to address reimbursement of procedural or pain management services that are an integral part of anesthesia services as well as anesthesia services that are an integral part of procedural services. UnitedHealthcare Oxford Clinical Policy Effective 02/01/2018 ©1996-2018, Oxford Health Plans, LLC Paroxysmal nocturnal hemoglobinuria (PNH)1 Soliris is medically necessary when all of the following criteria are met: o Initial Therapy: Documentation supporting the diagnosis of PNH with at least one of the following criteria: Want to access your card online? Register for Medicare member site.