Pharmacy Prior Authorization Criteria

Lumvoa (veligrotug-vvze)

Indications for Prior Authorization

Lumvoa (veligrotug-vvze)

• For diagnosis of Thyroid Eye Disease (TED)
  Indicated for the treatment of thyroid eye disease regardless of Thyroid Eye Disease (TED) activity or duration.

Criteria

Lumvoa

Prior Authorization

Length of Approval: 6 Month(s)

• Diagnosis of moderate-to-severe thyroid eye disease (TED), confirmed by both of the following:
• Clinical Activity Score (CAS) ≥ 4
• Orbital imaging (CT or MRI) confirming extraocular muscle or orbital fat involvement
AND
• Trial and failure (minimum of 12 weeks), contraindication, or intolerance to at least 4.5 g IV glucocorticoid therapy (e.g., IV methylprednisolone)
AND
• Prescribed by or in consultation with one of the following:
• Endocrinologist
• Ophthalmologist
AND
• Treatment with Lumvoa has not exceeded a total of 5 infusions over 12 week course [A, 1]
AND
• Requested drug will not be used in combination with Tepezza (teprotumumab)

P & T Revisions

2026-08-13

References

1. Lumvoa prescribing information. Viridian Therapeutics, Inc. Waltham, MA. June 2026.
2. Burch, H., Perros, P., Bednarczuk, T., et al. Management of Thyroid Eye Disease: A Consensus Statement by the American Thyroid Association and the European Thyroid Association. Available at: https://www.liebertpub.com/doi/10.1089/thy.2022.0251. Accessed July 9, 2026.
3. L Bartalena, G J Kahaly, L Baldeschi, et. al. The 2021 European Group on Graves’ orbitopathy (EUGOGO) clinical practice guidelines for the medical management of Graves’ orbitopathy, European Journal of Endocrinology, Volume 185, Issue 4, Oct 2021, Pages G43–G67.

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End Notes

1. In the pivotal trials, patients were given intravenous infusions (10 mg/kg) every 3 weeks for a total of 5 infusions. [1]

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Revision History

• 2026-08-13: New Program.

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