CurrentUnitedHealthcarePolicy CSOH2025D0047.B

Factor Mimetics Rebalancing Agents Hemophilia Oh Cs

Ohio-only UnitedHealthcare Medical Benefit Drug Policy addressing coverage of specified factor mimetics and rebalancing agents for hemophilia. References Ohio Department of Medicaid Unified Preferred Drug List Criteria and Ohio Administrative Code for medical necessity determinations.

Policy Summary

PayerUnitedHealthcare

PolicyFactor Mimetics Rebalancing Agents Hemophilia Oh Cs

Policy CodePolicy CSOH2025D0047.B

Change TypeRevised

Effective DateNov 1, 2025

Next Review Date

Key ActionProviders must reference and satisfy the Ohio Department of Medicaid Unified Preferred Drug List Criteria and Ohio Administrative Code 5160-1-01 when requesting coverage; prior authorization requirements and medical necessity determinations are governed by Ohio Medicaid criteria.

SourceLink

POLICY UPDATE CHANGES

Revised list of applicable factor mimetics and rebalancing agents for hemophilia; added Qfitlia (fitusiran).

4Listed agents

Coverage Summary

This is an Ohio-only UnitedHealthcare Medical Benefit Drug Policy that lists factor mimetics and rebalancing agents considered medically necessary in certain circumstances for hemophilia management. Coverage determinations and specific medical necessity evaluations are made using the Ohio Department of Medicaid Unified Preferred Drug List Criteria and, when services are stated as unproven or limited, Ohio Administrative Code 5160-1-01.

ALL of the following

ONE of
- Alhemo (concizumab-mtci)
- Hemlibra (emicizumab-kxwh)
- Hympavzi (marstacimab-hncq)
- Qfitlia (fitusiran)
Clinical coverage criteria from the Ohio Department of Medicaid Unified Preferred Drug List Criteria are met
Refer to Ohio Medicaid UPL Criteria for specific patient-level indications, prior authorization, and medical necessity requirements

ref

title

Provider Actions & Prior Authorization

Prior Authorization

Follow Ohio Medicaid UPL criteria and state rules

Providers must reference and satisfy the Ohio Department of Medicaid Unified Preferred Drug List Criteria and Ohio Administrative Code 5160-1-01 when requesting coverage; prior authorization requirements and medical necessity determinations are governed by Ohio Medicaid criteria.

Prior authorization and medical necessity are governed by Ohio Medicaid UPL and OAC 5160-1-01
Providers must reference the Ohio Department of Medicaid Unified Preferred Drug List Criteria

Operational impact: This policy applies only in Ohio and requires providers to follow the Ohio Department of Medicaid Unified Preferred Drug List Criteria. Prior authorization and medical necessity requirements are governed by Ohio Medicaid criteria and Ohio Administrative Code 5160-1-01.

Clinical Evidence & Rationale

Coverage rationale change: The Coverage Rationale was revised to add Qfitlia (fitusiran) to the list of applicable factor mimetics and rebalancing agents. The policy continues to state that these agents are considered medically necessary in certain circumstances with clinical criteria referenced to the Ohio Medicaid UPL.

Background & Definitions

Background: This Medical Benefit Drug Policy applies only to the state of Ohio and addresses coverage of specified factor mimetics and rebalancing agents for hemophilia. Evaluations of unproven services or services with coverage or quantity limits will be conducted using Ohio Administrative Code 5160-1-01.

Application: This policy applies only to the state of Ohio; evaluations of unproven services or services with coverage/quantity limits will use Ohio Administrative Code 5160-1-01.