On Oct. 1, UnitedHealthcare (UHC) announced updates to its policies for Actemra, Benlysta, Cimzia, Orencia, Simponi Aria and Stelara. The policy changes were effective immediately and required all patients to fail to respond to the self-administered formulation of these drugs prior to obtaining authorization for the physician-administered product. An exception would be granted only if the physician could attest that both the patient and caregiver were unable to administer the drug.
UHC has since delayed the policy changes for Actemra, Benlysta, Cimzia, Orencia and Simponi Aria. Practices should instead refer to the policies that were in effect prior to Oct. 1 for these drugs. The changes to the Stelara policy remain in effect. If a valid prior authorization is in place for office-administered Stelara, it will be honored until its expiration; however, the ACR encourages members to watch these changes closely. UHC has indicated the delayed policies are still under consideration, although no future effective date has been set.
The ACR opposes the requirement to mandate self-administered formulations first and is actively working with other rheumatology groups to advocate for the permanent rescission of the policies.
If you have questions regarding this policy or other insurance coverage concerns, contact [email protected].