Overview

Clinical Criteria

Overview

Coding

Document history

References

This document addresses the use of Veklury (remdesivir), a SARS-CoV-2 nucleotide analog RNA polymerase inhibitor approved by the Food and Drug Administration for the treatment of coronavirus disease 2019 (COVID-19) requiring hospitalization in individuals 12 years of age and older (weighing at least 40 kg). Veklury is administered intravenously with a loading dose of 200 mg on day one followed by 100 mg once daily. For individuals requiring invasive mechanical ventilation and/or extracorporeal membrane oxygenation (ECMO), the recommended total treatment duration is 10 days. For individuals not requiring invasive mechanical ventilation and/or ECMO, the recommended total treatment duration is 5 days but can be extended to 10 days if the individual does not demonstrate clinical improvement. Veklury should only be administered in a hospital or in a healthcare setting capable of providing acute care comparable to inpatient hospital care.

Clinical Criteria

When a drug is being reviewed for coverage under a member’s medical benefit plan or is otherwise subject to clinical review (including prior authorization), the following criteria will be used to determine whether the drug meets any applicable medical necessity requirements for the intended/prescribed purpose.

• Requests for Veklury (remdesivir) may be approved if the following criteria are met:
• I. Individual is using for the treatment of a laboratory confirmed COVID-19 infection; AND
• II. Veklury will be administered in a hospital or healthcare setting capable of providing acute care comparable to inpatient hospital care.

Veklury (remdesivir) may not be approved when the above criteria are not met and for all other indications.

Approval Duration: One month

Quantity Limits

Veklury (remdesivir) Quantity Limit

Veklury (remdesivir) 100 mg vial
11 vials per month

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement

• J3490

• XW033E5
• XW043E5

Unclassified drugs (when specified as [Veklury] (remdesivir))

• Introduction of VEKLURY Anti-infective into Peripheral Vein, Percutaneous Approach, New Technology Group 5
• Introduction of VEKLURY Anti-infective into Central Vein, Percutaneous Approach, New Technology Group 5

• U07.1 - COVID-19

Document History

Revised: 8/20/2021