Vemlidy (tenofovir alafenamide) — United Healthcare

Chronic hepatitis B infection

Preferred products

Diagnosis of chronic hepatitis B infection
AND Both of the following:
Submission of medical records documenting one of the following: Patient has a history of adverse event or intolerance to entecavir (generic Baraclude) OR Patient is not a suitable candidate for entecavir (generic Baraclude)
AND One of the following:
Submission of medical records documenting a history of adverse event or intolerance to tenofovir disoproxil fumarate (generic Viread)
OR Submission of medical records documenting an estimated glomerular filtration rate below 90 mL/min
OR Submission of medical records documenting a diagnosis of osteopenia as defined by a BMD T-score between -1 and -2.5 (BMD T-score greater than -2.5 and less than or equal to -1) based on BMD measurements from lumbar spine (at least two vertebral bodies), hip (femoral neck, total hip), or radius (one-third radius site) with evidence of progressive bone loss on serial DEXA scan
OR Submission of medical records documenting a diagnosis of osteoporosis as defined by a BMD T-score ≤ -2.5 based on BMD measurements from lumbar spine (at least two vertebral bodies), hip (femoral neck, total hip), or radius (one-third radius site)
OR Submission of medical records documenting a prior low-trauma or nontraumatic fracture
OR Patient is less than 20 years of age

Documentation of positive clinical response to Vemlidy therapy
AND Patient is not a suitable candidate for entecavir (generic Baraclude) or tenofovir disoproxil fumarate (generic Viread)

12 months