CurrentUnitedHealthcarePolicy CSIND0067.06

Alpha1-Proteinase Inhibitors (for Indiana Only)

Defines UnitedHealthcare Community Plan medical benefit coverage for alpha1-proteinase inhibitor products for members in Indiana, referencing InterQual Specialty Rx Non-Oncology Alpha 1 Proteinase Inhibitor clinical criteria. Affects providers submitting medical benefit drug requests for these products in Indiana.

Policy Summary

PayerUnitedHealthcare

PolicyAlpha1-Proteinase Inhibitors (for Indiana Only)

Policy CodePolicy CSIND0067.06

Change TypeRoutine review (no material changes)

Effective DateNov 1, 2025

Next Review Date

Key ActionSubmit prior authorization requests citing applicable HCPCS codes (J0256, J0257) and documentation that meets the InterQual criteria.

SourceLink

POLICY UPDATE CHANGES

Routine review; no content changes.

4products named

2HCPCS codes

Indianaapplicability

InterQualexternal criteria

Coverage Criteria

Policy Summary

PayerUnitedHealthcare

PolicyAlpha1-Proteinase Inhibitors (for Indiana Only)

Policy CodePolicy CSIND0067.06

Change TypeRoutine review (no material changes)

Effective DateNov 1, 2025

Next Review Date

Key ActionSubmit prior authorization requests citing applicable HCPCS codes (J0256, J0257) and documentation that meets the InterQual criteria.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for coverage determination. Coverage decisions are made based on the current InterQual medical necessity criteria for Specialty Rx Non-Oncology Alpha 1 Proteinase Inhibitor. Providers must obtain prior authorization before delivering therapy when required by the member's benefit plan.

Prior authorization required prior to service when member's benefit plan requires PA
Coverage determined using the current InterQual guideline

Denial Risk

Denial Risk for Unmet InterQual Criteria

Requests that do not meet the InterQual medical necessity criteria may be denied. Providers should ensure submitted documentation clearly demonstrates that the member meets all applicable InterQual criteria to avoid denial.

Denial risk if InterQual criteria not met
Appeals available per contract terms if claim is denied

Documentation Required

Documentation and Benefit Plan Reference

When submitting prior authorization requests or medical records, providers must include clinical documentation that demonstrates how the member meets InterQual criteria and must reference the applicable federal, state, and contractual benefit plan requirements. In the event of any conflict, the federal, state, or contractual requirements govern coverage.

Include relevant clinical notes, diagnostic test results, prior therapies, and dosing information
Reference the member's federal/state/contractual benefit plan when requesting coverage

Note

Provider Action Required

Providers must take action to obtain any required authorizations and submit complete documentation as outlined above. Failure to follow these provider actions may result in denial of coverage or payment.

Obtain prior authorization when required
Submit complete clinical documentation tied to InterQual criteria and benefit plan terms

Initial Therapy Criteria

Initial Therapy

Initial coverage decisions follow InterQual medical necessity criteria.

Initial therapy per InterQual: Initial requests must meet the InterQual Specialty Rx Non-Oncology Alpha 1 Proteinase Inhibitor criteria.see InterQual

Providers must supply documentation to demonstrate criteria are met.

Background

Alpha1-proteinase inhibitors (Aralast NP, Glassia, Prolastin-C, and Zemaira) are plasma-derived replacement therapies used to treat patients with alpha-1 antitrypsin deficiency to reduce degradation of lung tissue. UnitedHealthcare relies on the InterQual Specialty Rx Non-Oncology Alpha 1 Proteinase Inhibitor guideline for the specific medical necessity criteria that determine coverage for these products.

Definitions

InterQual criteria — external clinical criteria reference

External clinical criteria referencedInterQual Specialty Rx Non-Oncology Alpha 1 Proteinase Inhibitor

How criteria are appliedCoverage determined when patient meets the medical necessity criteria in the current release of the InterQual guideline

Effect of not meeting criteriaUse not meeting InterQual criteria may be considered not medically necessary

Location of InterQual detailsSee current InterQual guideline (link provided in policy) for specific entry and continuation criteria

OpenPayer