Anthem: Briumvi Payer Policy (Beta Access)

Note: When Briumvi (ublituximab) is deemed approvable based on the clinical criteria referenced, the benefit plan may have additional criteria requiring the use of a preferred1 agent or agents.

Briumvi (ublituximab) may not be approved for the following: 

• Use in combination with other MS disease modifying agents (including Aubagio, Avonex, Bafiertam, Betaseron, Copaxone/Glatiramer/Glatopa, Extavia, Gilenya, Kesimpta, Lemtrada, Mavenclad, Mayzent, Ocrevus, Plegridy, Ponvory, Rebif, Tascenso ODT, Tecfidera, Tysabri, Vumerity and Zeposia); 

OR 

• Individual is using to treat non-active secondary progressive multiple sclerosis; 

OR 

• Individual is using to treat primary progressive multiple sclerosis; OR IV. Individual has active hepatitis B or another active infection at initiation of therapy; OR V. May not be approved when the above criteria are not met and for all other indications.
  

• Briumvi (ublituximab) 150 mg/6 mL vial - 450 mg (3 vials) every 24 weeks 

Initial Approval Criteria

Requests for Briumvi (ublituximab) may be approved if the following criteria are met: 

• Individual has a diagnosis of relapsing multiple sclerosis (RMS) (including clinically isolated syndrome, relapsing-remitting disease or active secondary progressive disease); AND
  • Individual is able to ambulate without aid or rest for at least 100 meters; AND 
    • If initiating therapy, individual has experienced at least two relapses within the previous two years or one relapse within the previous year or at least one T1 gadolinium-enhancing lesion on MRI within the previous year. 

Briumvi Step Therapy

    Requests for Briumvi (ublituximab) may be approved when the following criteria are met: 

• Documentation is provided that individual has been on Briumvi (ublituximab); OR 

• Documentation has been provided that individual has had a trial and inadequate response (including but not limited to clinical relapse, new or enlarged lesions on MRI or confirmed disability progression) or intolerance to the following: 

  • A. Preferred fumaric acid derivative; OR 

• Documentation is provided that individual has high disease activity despite treatment with fingolimod (Gilenya, Tascenso ODT) defined as the following (AAN 2018, Devonshire 2012): 

  • A. At least one relapse in the previous year while on therapy; AND 

  • B. At least 9 T2-hyperintense lesions in cranial MRI; 

    • OR 

  • C. At least one Gadolinium-enhancing lesion.

Preferred, as used herein, refers to agents that were deemed to be clinically comparable to other agents in the same class or disease category but are preferred based upon clinical evidence and cost effectiveness. 

Sources: https://files.providernews.anthem.com/4281/CC-0227_Pub-03-01-2024.pdf

Additional Resources

Medical Specialty Precertification Drug List: https://file.anthem.com/06347MUPENABS.pdf

Medical Step Therapy Drug List: https://file.anthem.com/A02605ANPENABS.pdf

Site of Care Drug List: https://file.anthem.com/06346MUPENABS.pdf