Priority Health: Briumvi Payer Policy (Beta Access)

TABLE OF CONTENTS

• Priority Health: Briumvi Payer Policy (Beta Access)
• MEDICAID
  • Continuation Criteria
• COMMERCIAL
  • Preferred Agents
  • Eligibility Requirements
  • Continuation Criteria

MEDICAID

Approval Timeframe:
Initial Authorization: 2 years 
Continuation Authorization: 2 years

Prescriber Specialty Requirement:

• The prescribing physician must be a Neurologist or a specialist in Multiple Sclerosis (MS).

Age Limitation:

• Patients must be 18 years or older to qualify for Briumvi therapy.

Dose & Frequency:

• Treatment must adhere to the FDA-approved dose and frequency based on the diagnosed MS subtype.

Initial Authorization Criteria:

• Documentation is required to confirm a diagnosis of one of the following:

  • Primary Progressive Multiple Sclerosis (PPMS)

  • Relapsing-Remitting Multiple Sclerosis (RRMS)

  • Secondary Progressive Multiple Sclerosis (SPMS)

Additional Information:

• Medical Policy Requirement:

  • Briumvi is subject to Priority Health’s Medical Policy 91414 - Infusion Services and Equipment.

  • Medications must be administered in an outpatient hospital infusion center.

Combination Therapy Restriction:

• Briumvi will not be approved in combination with any other disease-modifying therapy for MS.

Continuation Criteria

• Therapy may be discontinued if:

  • The patient is noncompliant with medical or pharmacologic therapy.

  • There is no demonstrable clinically significant improvement in the patient's condition after initiating Briumvi therapy.

Sources:

https://www.priorityhealth.com/-/media/DAAE5553F48C4FDBA84BABBAE764BB84.pdf

COMMERCIAL

Preferred Agents:

• Ocrevus (ocrelizumab)
• Ocrevus Zunovo (ocrelizumab/hyaluronidase)
• Briumvi (ublituximab)

Eligibility Requirements:

To qualify for coverage, patients must meet the following criteria:

• A definitive diagnosis of Primary Progressive Multiple Sclerosis (PPMS) confirmed by a neurologist or MS specialist.
• A diagnosis of multiple sclerosis, including relapsing-remitting MS (RRMS) or secondary progressive MS, confirmed by a neurologist or MS specialist.

Continuation Criteria

• Not Specified

Sources:

https://www.priorityhealth.com/-/media/81DACE8F00FF442799502209CC51780F.pdf