CurrentColorado Rocky Mountain Health PlansPolicy CSOH2025D0003.C

Rituximab (Riabni, Rituxan, Ruxience, & Truxima) (for Ohio Only)

Medical benefit drug policy governing coverage and medical necessity of intravenous rituximab products for non-oncology indications in Ohio; affects providers requesting rituximab for covered members under Ohio jurisdiction.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyRituximab (Riabni, Rituxan, Ruxience, & Truxima) (for Ohio Only)

Policy CodePolicy CSOH2025D0003.C

Change TypeRoutine review (no content changes)

Effective DateNov 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests that meet the current InterQual Specialty Rx Non‑Oncology rituximab criteria for the specific product.

SourceLink

POLICY UPDATE CHANGES

Routine review; no content changes.

4rituximab products named

4HCPCS codes listed

Ohioapplicability

InterQualExternal criteria

Coverage Criteria — Non-Oncology IV Rituximab

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Initial and ongoing coverage (non-oncology)

Covered when ALL InterQual non-oncology criteria for the specific rituximab product are met.

InterQual criteria: Member meets the current InterQual Specialty Rx Non-Oncology guideline criteria for the requested rituximab product (product-specific InterQual guideline referenced).

Policy lists product-specific InterQual guideline names: Riabni, Rituxan, Ruxience, Truxima.

This policy specifically excludes oncology indications for rituximab. Oncology uses are governed by the separate Oncology Medication Clinical Coverage (for Ohio Only) policy and related National Comprehensive Cancer Network (NCCN) guidance; providers should refer to that oncology policy for coverage determinations for cancer indications.

The listed procedure codes are provided for reference only. Listing a code does not imply that the service is covered or guarantee reimbursement; benefit coverage is determined by applicable federal, state, or contractual requirements and laws. Use those governing documents to determine whether a service is covered or non‑covered for a given member.

Provider Action Required / Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization required. Requests for non-oncology IV rituximab products must meet InterQual Specialty Rx Non‑Oncology rituximab criteria for the specific product requested (e.g., Riabni, Rituxan, Ruxience, Truxima, or another FDA‑approved rituximab biosimilar). Follow the InterQual sequencing, step, and documentation requirements referenced for each product.

Affected products: Riabni (rituximab‑arrx), Rituxan (rituximab), Ruxience (rituximab‑pvvr), Truxima (rituximab‑abbs), and other FDA‑approved rituximab biosimilars
Prior authorization is guided by the current InterQual criteria for the specific rituximab product requested
Follow any step‑therapy or sequencing requirements included in the InterQual guideline for the applicable product

Documentation Required

Reference Governing Benefit Documents

When deciding coverage, reference and follow governing benefit documents. Federal law, state requirements (including the Ohio Administrative Code where applicable), and the member’s contractual plan documents may supersede this policy. In case of conflict between this policy and federal, state (OAC), or contractual requirements, the federal, state (OAC), or contractual requirements govern. Verify plan‑specific coverage before authorization.

Check member’s plan contract and applicable federal/state laws prior to approving or denying requests
This policy is informational and does not replace plan contract language or legal requirements

Billing Rule

Coding Inclusion Is Not Authorization

Listing a procedure or diagnosis code in this policy is for reference only and does not guarantee coverage or payment. Inclusion of a code does not imply authorization. Benefit coverage is determined by federal, state, or contractual requirements and applicable law.

Reference codes: J9312; Q5115; Q5119; Q5123 — inclusion here does not imply the service is covered or authorized

Definitions

Rituximab (non-hyaluronidase formulations) — definition and scope

IncludesRiabni (rituximab-arrx); Rituxan (rituximab); Ruxience (rituximab-pvvr); Truxima (rituximab-abbs); any FDA‑approved rituximab biosimilar not listed.

Definition'Rituximab' refers to all rituximab products without hyaluronidase.

Coverage governanceNon-oncology clinical coverage determinations defer to the current InterQual Specialty Rx Non-Oncology guideline for the specific rituximab product referenced (product-specific InterQual guideline names provided).

Oncology indicationsOncology indications are excluded from this policy; refer to the Oncology Medication Clinical Coverage (for Ohio Only) policy and NCCN where applicable.

InterQual guideline examplesProduct-specific InterQual guideline names: Riabni: CP: Specialty Rx Non-Oncology, Rituximab-arrx (Riabni); Rituxan: CP: Specialty Rx Non-Oncology, Rituximab (Rituxan); Ruxience: CP: Specialty Rx Non-Oncology, Rituximab-pvvr (Ruxience); Truxima: CP: Specialty Rx Non-Oncology, Rituximab-abbs (Truxima).

Initial Therapy

Initial authorization requires meeting product-specific InterQual non-oncology criteria.

Initial authorization: Request meets the current InterQual Specialty Rx Non-Oncology guideline for the specific rituximab product being requested.

InterQual guideline links provided in policy.

Step	Requirement
1
Follow the InterQual Specialty Rx Non-Oncology sequencing or step requirements referenced for the requested rituximab product (see product-specific InterQual guideline for Riabni, Rituxan, Ruxience, or Truxima).

Site of Care

Note

Follow InterQual and plan rules for infusion site‑of‑care

Intravenous rituximab formulations (non-hyaluronidase) are administered in infusion settings; site‑of‑care determinations should follow InterQual guidance and any plan‑specific coverage rules.

Determine site of care (for example, infusion center) per InterQual recommendations and the member’s plan rules.

Biosimilar Products

Billing Rule

Rituxan coverage follows InterQual product‑specific criteria

Rituxan (rituximab) is listed among the rituximab products covered by InterQual criteria; follow the InterQual Specialty Rx Non‑Oncology guideline for product‑specific medical necessity determinations.

Use the InterQual guideline titled “CP: Specialty Rx Non‑Oncology, Rituximab (Rituxan)” for coverage decisions involving Rituxan.

Billing Rule

Truxima coverage follows InterQual product‑specific criteria

Truxima (rituximab‑abbs) is included as a rituximab product governed by the corresponding InterQual Specialty Rx Non‑Oncology guideline; apply the product‑specific InterQual criteria when requesting coverage.

Refer to “CP: Specialty Rx Non‑Oncology, Rituximab‑abbs (Truxima)” in InterQual for medical necessity requirements.

Billing Rule

Riabni coverage follows InterQual product‑specific criteria

Riabni (rituximab‑arrx) is an included biosimilar product; coverage determinations should follow the InterQual Specialty Rx Non‑Oncology guideline specific to Riabni.

Use the InterQual guideline “CP: Specialty Rx Non‑Oncology, Rituximab‑arrx (Riabni)” for authorization decisions.

Background

Rituximab is an intravenous anti‑CD20 monoclonal antibody and, for the purposes of this policy, refers to rituximab products without hyaluronidase (including Riabni, Rituxan, Ruxience, Truxima, and any FDA‑approved biosimilars not listed). This policy applies to non‑oncology indications only and delegates medical necessity determinations to the current InterQual® Specialty Rx Non‑Oncology rituximab guidelines referenced for each specific product; providers should follow the product‑specific InterQual criteria when requesting authorization.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyRituximab (Riabni, Rituxan, Ruxience, & Truxima) (for Ohio Only)

Policy CodePolicy CSOH2025D0003.C

Change TypeRoutine review (no content changes)

Effective DateNov 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests that meet the current InterQual Specialty Rx Non‑Oncology rituximab criteria for the specific product.

SourceLink

On This Page

OpenPayer

Rituximab (Riabni, Rituxan, Ruxience, & Truxima) (for Ohio Only)

Coverage Criteria — Non-Oncology IV Rituximab

Billing and Coding

Provider Action Required / Prior Authorization

Definitions

Initial Therapy

Continuation Therapy

Step Therapy / Sequencing

Site of Care

Biosimilar Products

Background

J9312	Injection, rituximab, 10 mg.
Q5115	Injection, rituximab-abbs, biosimilar, (Truxima), 10 mg.
Q5119	Injection, rituximab-pvvr, biosimilar, (Ruxience), 10 mg.
Q5123	Injection, rituximab-arrx, biosimilar, (Riabni), 10 mg.