CurrentUnitedHealthcarePolicy CSIND0028.06

Erythropoiesis-Stimulating Agents (for Indiana Only)

Indiana-specific UnitedHealthcare medical benefit drug policy for erythropoiesis-stimulating agents (Aranesp, Epogen, Procrit, Retacrit, Mircera), referencing InterQual clinical criteria for medical necessity and providing applicable HCPCS/J-codes for billing reference.

Policy Summary

PayerUnitedHealthcare

PolicyErythropoiesis-Stimulating Agents (for Indiana Only)

Policy CodePolicy CSIND0028.06

Change TypeRoutine review; no content changes

Effective DateApr 1, 2025

Next Review Date

Key ActionProviders must refer to and document that the patient's indication meets the current InterQual clinical criteria specified for the selected ESA (links provided in policy).

POLICY UPDATE CHANGES

Routine review; no content changes.

5Listed ESA products

3Epoetin alfa product codes listed

1State-specific policy (Indiana)

Coverage Summary

This Indiana-specific UnitedHealthcare medical benefit drug policy is covered_with_criteria. It applies to erythropoiesis-stimulating agents (ESAs) included in the policy: Aranesp (darbepoetin alfa), Epogen / Procrit (epoetin alfa), Retacrit (epoetin alfa-epbx), and Mircera (methoxy polyethylene glycol-epoetin beta). Coverage is available when the patient's indication meets the current InterQual clinical criteria specified for the selected ESA (see InterQual CP references for each product). Relevant HCPCS/J- and Q-codes are provided in the policy for billing/reference.

Provider Actions & Documentation Requirements

Documentation Required

Use InterQual criteria for medical necessity

Refer to and document that the patient’s indication meets the current InterQual clinical criteria specified for the selected erythropoiesis‑stimulating agent. Note that links to the InterQual criteria are provided in the policy and the InterQual criteria set is required for the medical necessity coverage determination per policy language.

InterQual clinical criteria set is required for coverage determination per policy language.

Applicable Codes

J-codes (reference)HCPCS

J0881	Injection, darbepoetin alfa, 1 mcg (non-ESRD use)
J0882	Injection, darbepoetin alfa, 1 mcg (for ESRD on dialysis)
J0885	Injection, epoetin alfa, (for non-ESRD use), 1000 units
J0887	Injection, epoetin beta, 1 microgram, (for ESRD on dialysis)
J0888	Injection, epoetin beta, 1 microgram, (for non-ESRD use)

Q-/Instructional codes (reference)HCPCS

Q4081	Injection, epoetin alfa, 100 units (for ESRD on dialysis)
Q5105	Injection, epoetin alfa-epbx, biosimilar (Retacrit) (for ESRD on dialysis), 100 units
Q5106	Injection, epoetin alfa-epbx, biosimilar (Retacrit) (for non-ESRD use), 1000 units

Background

Background: This policy addresses coverage of erythropoiesis-stimulating agents (ESAs) and defers to the current InterQual clinical criteria to determine medical necessity for the listed ESAs. It is intended to assist interpretation of UnitedHealthcare standard benefit plans for Indiana and does not override federal, state, or contractual requirements; in the event of conflict, federal, state, or contractual requirements govern. UnitedHealthcare may use third-party tools such as InterQual to assist in administering benefits, and the policy is informational and not medical advice.

Definitions: InterQual — Third-party clinical criteria set used by UnitedHealthcare to determine medical necessity for the listed ESAs.