CurrentColorado Rocky Mountain Health PlansPolicy CSOH2026D0034.K

Maximum Dosage and Frequency (for Ohio Only) – Community Plan Medical Benefit Drug Policyopen_in_new

Defines maximum dosage per administration and dosing frequency (HCPCS units and NDC quantities) for numerous provider-administered medications in Ohio, and states that doses beyond labeled or evidence-supported maxima are unproven and not medically necessary.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyMaximum Dosage and Frequency (for Ohio Only) – Community Plan Medical Benefit Drug Policyopen_in_new

Policy CodePolicy CSOH2026D0034.K

Change TypeAdded products, HCPCS/Q/J codes, and NDCs

Effective DateMay 1, 2026

Next Review Date

Key ActionProviders should ensure and document that administered doses do not exceed the policy's maximum dosage per administration and frequency based on weight/BSA or set maximal dose; durable documentation is needed when requesting doses beyond listed maxima for medical necessity review.

SourceLink

POLICY UPDATE CHANGES

Revised list of applicable drug products to add denosumab-bmwo (Stoboclo & Osenvelt).

Revised list of applicable drug products to add denosumab-bnht (Bomyntra & Conexxence) and denosumab-nxxp (Bildyos & Bilprevda).

Revised list of applicable drug products to add eculizumab-aagh (Epysqli) and eculizumab-aeeb (Bkemv).

Revised list of applicable drug products to add ustekinumab-srlf (Imuldosa).

Added maximum allowed quantities by HCPCS units for multiple newly listed products including Bildyos, Bilprevda, Bkemv, Bomyntra, Conexxence, Epysqli, Imuldosa, Osenvelt, and Stoboclo.

Added maximum allowed quantities for National Drug Code (NDC) billing for the newly listed products with specific NDCs.

Added maximum allowed frequencies for Bildyos (denosumab-nxxp) and Bilprevda (denosumab-nxxp).

Updated References section and archived previous policy version CSOH2025D0034.J.

Coverage Summary & Scope

General Coverage, Not Medically Necessary, and Application

General Coverage Criteria

Covered when ALL of the following are met:

ALL of the following

Dose administered is within the maximum dosage per administration (based on body surface area, patient weight, or a set maximal dose independent of body size) specified in this policy.
Use is according to the product’s labeled indications or supported by published clinical evidence (for example, well-designed systematic reviews, randomized controlled trials, or authoritative guidelines such as NCCN).

Not Medically Necessary / Unproven

Not medically necessary / Unproven when ALL of the following apply:

ALL of the following

Medication is administered beyond the maximum dosages and/or dosing frequency defined in this policy (based on body surface area, patient weight, or set maximal dose).
Use beyond the maximum dosage and/or frequency is not supported by the product labeling or published clinical evidence.

Application

Application:

ALL of the following

This Medical Benefit Drug Policy applies only to the state of Ohio.
Requests for services stated as unproven or those subject to coverage or quantity limits will be evaluated for medical necessity using Ohio Administrative Code 5160-1-01.

Provider Requirements and Billing Rules

Note

Applicable Codes and Maximum Allowed Quantities

Maximum Allowed Quantities by HCPCS Units (covered within limits)HCPCSCovered

J3262	tocilizumab — 800 units (1 mg per unit)
Q5133	tocilizumab-bavi (Tofidence) — 800 units (1 mg per unit)
Q5135	tocilizumab-aazg (Tyenne) — 800 units (1 mg per unit)
J9035	bevacizumab (Avastin) — 240 units (10 mg per unit) based on 15 mg/kg
Q5129	bevacizumab-adcd (Vegzelma) — 240 units (10 mg per unit)
Q5107	bevacizumab-awwb (Mvasi) — 240 units (10 mg per unit)
Q5118	bevacizumab-bvzr (Zirabev) — 240 units (10 mg per unit)
Q5126	bevacizumab-maly (Alymsys) — 240 units (10 mg per unit)
J3145	testosterone undecanoate (Aveed) — 750 units (1 mg per unit)
J0585	onabotulinumtoxinA (Botox) — 600 units (1 unit per HCPCS unit)

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Background & Evidence Basis

Policy Revisions

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyMaximum Dosage and Frequency (for Ohio Only) – Community Plan Medical Benefit Drug Policyopen_in_new

Policy CodePolicy CSOH2026D0034.K

Change TypeAdded products, HCPCS/Q/J codes, and NDCs

Effective DateMay 1, 2026

Next Review Date

SourceLink

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