CurrentmhnPolicy CP.PHAR.224

LOVENOX (PDF)

Defines medical necessity criteria, initial and continued approval conditions, contraindications, dosing summaries, product availability, and coding implications for enoxaparin/Lovenox across Commercial, HIM, and Medicaid lines of business.

Policy Summary

Payermhn

PolicyLOVENOX (PDF)

Policy CodePolicy CP.PHAR.224

Change TypeClarified; Revised

Effective DateMay 1, 2016

Next Review Date

Key ActionProvider must submit documentation (e.g., office notes, lab results) supporting that member has met all approval criteria.

SourceLink

POLICY UPDATE CHANGES

Commercial approval duration for anticoagulation in pregnancy revised from '6 months' to 'antepartum to estimated delivery date; postpartum up to 6 months'.

Changed 'Member must use' language applied for requests for brand Lovenox to require use of generic enoxaparin unless contraindicated or adverse effects occur.

MultipleCovered Indications (FDA + off-label pregnancy + cancer-associated use)

1Referenced HCPCS code

6 monthsTypical approval duration (Medicaid/HIM)

6 monthsCommercial approval duration (standard)

Coverage Summary

Background: Enoxaparin (Lovenox) is a low molecular weight heparin (LMWH) indicated for prophylaxis and treatment of deep vein thrombosis (DVT) ± pulmonary embolism (PE), prophylaxis of ischemic complications in unstable angina/non-Q-wave myocardial infarction (when used with aspirin), and to reduce recurrent myocardial infarction or death in STEMI receiving thrombolysis (when used with aspirin). Policy scope: defines medical necessity criteria, initial and continued approval conditions (including anticoagulation in pregnancy), contraindications, dosing summaries, product availability, and coding implications across Commercial, HIM, and Medicaid lines of business. Coverage stance: covered_with_criteria. Effective/last review dates: effective 05.01.16; last review 02.26 (policy reflects 1Q2026 annual review updates).

I. Initial Approval Criteria - Thrombosis/Thromboembolism

Provider must submit documentation supporting that member has met all approval criteria. Enoxaparin/Lovenox is medically necessary when the following criteria are met:

ALL of the following

Indication (one of)
- Thrombosis or thromboembolism prevention associated with any of the following conditions: cancer; unstable angina or myocardial infarction; atrial fibrillation or prosthetic heart valve; major surgery - orthopedic or non-orthopedic; critical illness related to ICU admissions or events; restricted mobility associated with acute illnesses or conditions; implanted vascular devices (e.g., central venous access device, umbilical venous catheter, dialysis devices/fistulas, ventricular assist devices).
- Thrombosis or thromboembolism treatment.
- Short-term prophylaxis for transition to or from oral anticoagulation.
If request is for brand Lovenox, member must use generic enoxaparin, unless contraindicated or clinically significant adverse effects are experienced.

Initial Therapy Criteria

I.B Anticoagulation in Pregnancy: Ante- and Postpartum (off-label)

Must meet all

ALL of the following

Indication (one of)
- Acute venous thrombosis during current pregnancy
- Prior venous thrombosis
- Receiving long-term therapy with a vitamin K antagonist (e.g., warfarin)
- Prosthetic heart valve

Continuation Therapy Criteria

II.A Continued Therapy - Thrombosis/Thromboembolism

Must meet all

ALL of the following

ANY of the following
- Currently receiving medication via Centene benefit or member has previously met initial approval criteria.
- Member is currently receiving medication and is enrolled in a state and product with continuity of care regulations (refer to CC.PHARM.03A and CC.PHARM.03B state addendums).
Member is responding positively to therapy.
Continued use limited to any of

Unapproved / Not Authorized Indications

III. Diagnoses/Indications NOT authorized

Non-FDA approved indications which are not addressed in this policy, unless there is sufficient documentation of efficacy and safety according to off-label use policies (CP.CPA.09, HIM.PA.154, CP.PMN.53) or evidence of coverage documents.

Provider Actions & Authorization Requirements

Documentation Required

Submit supporting documentation

Submit documentation supporting that the member has met all approval criteria. Examples: office chart notes, laboratory results, or other clinical information.

Office chart notes
Lab results
Other clinical information

Prior Authorization

Brand vs generic requirement

Requests for brand Lovenox require use of generic enoxaparin unless the member has a contraindication or clinically significant adverse effects; this requirement applies to both initial and continued therapy.

J1650

Applicable Codes

Referenced HCPCS codesHCPCS

J1650

Injection, enoxaparin sodium, 10 mg

Note: This policy references HCPCS code J1650 (Injection, enoxaparin sodium, 10 mg). The requirement that members use generic enoxaparin when appropriate (versus brand Lovenox) may affect billing and prior authorization submissions; providers should consider coding implications when requesting brand product.

Clinical Evidence & References

Evidence: Primary reference is Lovenox Prescribing Information, Sanofi-Aventis; May 2025. Guideline support cited includes CHEST, ACOG, NCCN, and ASH guidance. The policy includes FDA indications and specified off-label uses such as anticoagulation in pregnancy and cancer-associated VTE consistent with NCCN recommendations.

Background

Background: Enoxaparin (Lovenox) is a low molecular weight heparin (LMWH) used for DVT/PE prophylaxis and treatment, for ischemic complication prophylaxis in unstable angina/NSTEMI, and to reduce recurrent MI/death in STEMI with thrombolysis. The policy explicitly includes FDA-approved indications and specified off-label uses such as anticoagulation in pregnancy (antepartum and postpartum) and cancer-associated venous thromboembolic disease per NCCN guidance. Definitions: DVT = deep vein thrombosis; LMWH = low molecular weight heparin; NCCN = National Comprehensive Cancer Network.

Quick Policy Facts

Typical approval duration (Medicaid/HIM)6 months

Commercial approval duration6 months or duration of request, whichever is less

Referenced HCPCS codeJ1650

Coverage stancecovered_with_criteria

Brand vs generic requirementIf request is for Lovenox, member must use generic enoxaparin unless contraindicated or clinically significant adverse effects are experienced.

Revision History

1Q2022non-material clarification

Wording changed to 'Member must use' for requests for brand Lovenox to require use of generic enoxaparin unless contraindicated or clinically significant adverse effects occur (clarification; no clinical policy statement changes).

1Q2026material changeLatest

Commercial approval duration for anticoagulation in pregnancy revised from '6 months' to 'antepartum to estimated delivery date; postpartum up to 6 months' to accommodate use during and after a full-term pregnancy (material change).

Policy Summary

Payermhn

PolicyLOVENOX (PDF)

Policy CodePolicy CP.PHAR.224

Change TypeClarified; Revised

Effective DateMay 1, 2016

Next Review Date

Key ActionProvider must submit documentation (e.g., office notes, lab results) supporting that member has met all approval criteria.

SourceLink

On This Page

Inherited thrombophilia

Antiphospholipid antibody syndrome

Development of severe ovarian hyperstimulation syndrome post assisted reproduction

Cesarean section - current pregnancy and request is for the postpartum period

Any other indication listed in section I.A

Member is pregnant or < 6 months postpartum

If request is for Lovenox, member must use generic enoxaparin, unless contraindicated or clinically significant adverse effects are experienced.

I.C Other diagnoses/indications

Must meet one or two

ANY of the following

If drug has recently (within last 6 months) undergone a label change not reflected in this policy, refer to applicable formulary/no-coverage or non-formulary policy (lists CP.CPA.190, HIM.PA.33, CP.PMN.255, HIM.PA.103, CP.PMN.16 as applicable).
If requested use is NOT listed under section III and criterion 1 does not apply, refer to off-label use policy for relevant line of business (CP.CPA.09, HIM.PA.154, CP.PMN.53).

Venous thrombosis prophylaxis or treatment in the presence of cancer.

Past history of failed anticoagulation therapy on a non-LMWH (e.g., heparin, fondaparinux, warfarin, apixaban, dabigatran, edoxaban, rivaroxaban).

Any other indication in section I.A where bridging to warfarin is inappropriate or member has a contraindication to warfarin and extended (indefinite) anticoagulation therapy is required.

If request is for Lovenox, member must use generic enoxaparin, unless contraindicated or clinically significant adverse effects are experienced.

II.B Continued Therapy - Anticoagulation in Pregnancy (off-label)

Must meet all

ALL of the following

ANY of the following
- Currently receiving medication via Centene benefit or member has previously met initial approval criteria.
- Member is currently receiving medication and is enrolled in a state and product with continuity of care regulations (refer to CC.PHARM.03A and CC.PHARM.03B).
Member is responding positively to therapy.
See Section II.A for continued anticoagulation therapy beyond 6 months postpartum.
If request is for Lovenox, member must use generic enoxaparin, unless contraindicated or clinically significant adverse effects are experienced.

Prior Authorization

Continuation eligibility

For continued therapy, the member must either be currently receiving the medication via the Centene benefit or have previously met initial approval criteria, or be currently receiving medication and enrolled in a state/product with continuity-of-care regulations; the member must also be responding positively to therapy.

Documentation Required

Refer to formulary/off-label policies for unlisted uses

If the requested use is not listed in the policy or the drug underwent a recent label change not reflected in this policy, consult the applicable formulary/no-coverage, non-formulary, or off-label use policies listed to determine coverage.

CP.CPA.190
HIM.PA.33
CP.PMN.255
HIM.PA.103
CP.PMN.16
CP.CPA.09
HIM.PA.154
CP.PMN.53