J0879, Injection, difelikefalin, 0.1 microgram, (for esrd on dialysis)
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- This Medical Benefit Drug Policy provides assistance in interpreting UnitedHealthcare standard benefit plans. When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may differ from the standard plan.
Key Coverage Criteria
- Indication: Korsuva is proven for treatment of moderate-to-severe pruritus associated with CKD in adults on hemodialysis, with initial therapy requiring diagnosis of CKD-associated pruritus, hemodialysis, FDA-labeled dosing, and initial authorization up to 12 months; continuation requires documentation of positive response, FDA-labeled dosing, and reauthorization up to 12 months.
- Coverage criterion: Korsuva is covered for the treatment of moderate-to-severe pruritus associated with CKD in adults on hemodialysis when (1) diagnosis of moderate-to-severe pruritus associated with CKD; (2) patient on hemodialysis; (3) dosing per FDA labeling; (4) initial authorization up to 12 months; continuation requires positive response, dosing per FDA labeling, and reauthorization up to 12 months.
- Korsuva (difelikefalin) is proven for the treatment of moderate-to-severe pruritus associated with chronic kidney disease in adults undergoing hemodialysis when the following criteria are met: For initial therapy, all of the following: o Diagnosis of moderate-to-severe pruritus associated with chronic kidney disease; and o Patient is on hemodialysis; and o Dosing is in accordance with the United States Food and Drug Administration approved labeling; and o Initial authorization will be for no lon [...]
- • For continuation of therapy, all of the following: o Documentation of a positive clinical response (i.e., reduction in itch from baseline); and o Dosing is in accordance with the United States Food and Drug Administration approved labeling; and o Reauthorization will be for no longer than 12 months
3 Active Policies
UHC-POL-korsuva, Korsuva (Difelikefalin)
UMR-POL-UMR-korsuva, Korsuva (Difelikefalin)
SUREST-POL-SUREST-korsuva, Korsuva (Difelikefalin)
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