CurrentUnitedHealthcarePolicy CSOH2025D0214.D

Nplate® (Romiplostim) (for Ohio Only) – Community Plan Medical Benefit Drug Policy

State-specific UnitedHealthcare Community Plan medical benefit drug policy for Nplate (romiplostim) applicable only to Ohio; coverage is determined by the InterQual CP: Specialty Rx Non-Oncology Romiplostim criteria and Ohio Administrative Code when indicated.

Policy Summary

PayerUnitedHealthcare

PolicyNplate® (Romiplostim) (for Ohio Only) – Community Plan Medical Benefit Drug Policy

Policy CodePolicy CSOH2025D0214.D

Change TypeRevised: removed specific indications; now references InterQual

Effective DateNov 1, 2025

Next Review Date

Key ActionProviders must document and support medical necessity consistent with the current InterQual CP: Specialty Rx Non-Oncology, Romiplostim criteria.

SourceLink

POLICY UPDATE CHANGES

Removed language pertaining to specific treatment indications and now refers to the InterQual criteria listed in the policy for applicable coverage guidelines.

1Referenced External Clinical Guideline

1HCPCS Codes Listed

Coverage Summary

State-specific UnitedHealthcare Community Plan medical benefit drug policy for Nplate (romiplostim) applicable only to Ohio. Coverage determinations defer to the current InterQual CP: Specialty Rx Non-Oncology, Romiplostim guideline for medical necessity criteria. In the event of conflict, federal, state, or contractual requirements govern and services stated as unproven or subject to limits will be evaluated using OAC 5160-1-01.

Coverage Rationale

Covered when criteria in the referenced InterQual guideline are met:

ALL of the following

Member is in Ohio (policy applies only to the state of Ohio).
Medical necessity for Nplate (romiplostim) is determined per the current release of the InterQual guideline: CP: Specialty Rx Non-Oncology, Romiplostim (Nplate).
Refer to InterQual criteria linked in policy for specific indications, initial and continuation criteria, and dosing limits.
If service is stated as unproven or subject to a coverage or quantity limit, evaluate using Ohio Administrative Code 5160-1-01.
State regulatory requirements govern in event of conflict with standard benefit plan.

Provider Actions / Billing

Documentation Required

Follow InterQual for medical necessity documentation

Providers must document and support medical necessity consistent with the current InterQual CP: Specialty Rx Non-Oncology, Romiplostim criteria; the policy defers to that guideline for specific coverage criteria and documentation requirements.

J2802

Prior Authorization

Prior authorization per InterQual

Prior authorization/coverage determinations should be based on the InterQual criteria and applicable Ohio Administrative Code; requests for services listed as unproven or with limits will be evaluated using OAC 5160-1-01.

J2802
OAC 5160-1-01

Billing Rule

Code use reference

When billing, report romiplostim using HCPCS code J2802 (Injection, romiplostim, 1 mcg) as appropriate.

J2802

Background & Definitions

This policy applies only to the state of Ohio. UnitedHealthcare may use third-party clinical criteria tools such as InterQual to determine medical necessity; for Nplate (romiplostim) the policy relies on the InterQual CP: Specialty Rx Non-Oncology, Romiplostim guideline. If there is a conflict with plan terms, federal, state (OAC), or contractual requirements govern, and services listed as unproven or with limits are evaluated per OAC 5160-1-01.

InterQual: A third-party clinical criteria tool used by UnitedHealthcare to determine medical necessity for specific drugs and services; this policy defers to the current InterQual Romiplostim guideline for coverage criteria.

OAC 5160-1-01: Ohio Administrative Code section referenced for evaluation of services stated as unproven or subject to coverage/quantity limits; governs in the event of conflict with plan terms.