CurrentUnitedHealthcarePolicy CSOH2026D0028.C

Erythropoiesis-Stimulating Agents (for Ohio Only)

This policy governs medical benefit coverage for specific erythropoiesis-stimulating agents (ESAs) for non‑oncology and oncology indications as applied to UnitedHealthcare members in Ohio.

Policy Summary

PayerUnitedHealthcare

PolicyErythropoiesis-Stimulating Agents (for Ohio Only)

Policy CodePolicy CSOH2026D0028.C

Change TypeRoutine review

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionFollow Ohio Department of Medicaid Unified Preferred Drug List Criteria for medical necessity and, for oncology indications, refer to the Oncology Medication Clinical Coverage policy.

SourceLink

POLICY UPDATE CHANGES

Routine review; no content changes.

5ESA products addressed

OhioState-specific applicability

8Procedure / HCPCS codes listed

2026-03-01Effective date

Coverage Criteria

Medically necessary ESA use (Ohio)

Covered when criteria in the applicable Ohio Department of Medicaid Unified Preferred Drug List or the Oncology Medication Clinical Coverage policy are met.

Covered ESAs: Aranesp (darbepoetin alfa), Epogen/Procrit/Retacrit (epoetin alfa), Mircera (MPG-epoetin beta) are considered medically necessary in certain circumstances.

For non-oncology indications follow the Ohio Department of Medicaid Unified Preferred Drug List Criteria; for oncology indications follow the Oncology Medication Clinical Coverage (for Ohio Only) referencing the NCCN Drugs & Biologics Compendium.

The listing of a procedure or HCPCS/Q-code in this policy is provided for reference only and does not imply the service described is a covered health service. Benefit coverage and payment are determined by applicable federal, state, or contractual requirements and laws; inclusion of a code here is not a guarantee of reimbursement or claim payment. Other policies and guidelines may apply.

Medical necessity determinations for erythropoiesis‑stimulating agents (ESAs) rely on the referenced Ohio criteria. For non‑oncology indications, follow the Ohio Department of Medicaid Unified Preferred Drug List Criteria. For oncology indications, refer to the Oncology Medication Clinical Coverage (for Ohio Only) policy (which incorporates NCCN Compendium guidance) when assessing coverage and authorization.

Policy Summary

PayerUnitedHealthcare

PolicyErythropoiesis-Stimulating Agents (for Ohio Only)

Policy CodePolicy CSOH2026D0028.C

Change TypeRoutine review

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionFollow Ohio Department of Medicaid Unified Preferred Drug List Criteria for medical necessity and, for oncology indications, refer to the Oncology Medication Clinical Coverage policy.

SourceLink

On This Page

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Coding and Billing Codes

Referenced HCPCS / Q-codesHCPCS

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)
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

Unit descriptors for listed HCPCS/Q-codes

J0881 / J0882 / J0887 / J0888Unit = 1 microgram (mcg) as specified in code descriptions

J0885 / Q5106Unit = 1000 units as specified in code descriptions

Q4081 / Q5105Unit = 100 units as specified in code descriptions

Provider Actions and Requirements

Prior Authorization

Prior Authorization and Coverage Determination (Ohio)

Prior authorization and coverage determinations for services described in this policy are governed by Ohio-specific requirements. Providers must follow state-specific criteria (Ohio Administrative Code 5160-1-01) and any applicable contractual requirements when requesting coverage. In the event of conflict between this policy and federal, state (OAC), or contractual requirements, the federal/state/contractual requirements govern.

State: Ohio Administrative Code 5160-1-01
Provider must verify plan-specific benefit language

Step Therapy

Step Therapy Reference

Step therapy and medical necessity criteria referenced in this policy follow the Ohio Department of Medicaid Unified Preferred Drug List Criteria. For non-oncology indications, providers should consult the Unified Preferred Drug List Criteria to determine applicable step therapy requirements prior to submission.

Applies to Aranesp, Epogen, Mircera, Procrit, Retacrit for non-oncology indications
For oncology indications, see Oncology Medication Clinical Coverage (for Ohio Only)

Documentation Required

Documentation and Determination Guidance

When evaluating coverage requests, UnitedHealthcare will reference and require documentation consistent with federal, state (OAC), and contractual requirements. Providers should furnish complete clinical documentation to support medical necessity determinations. If policy language conflicts with federal, state, or contractual requirements, those requirements take precedence and will be applied.

Provide clinical records that substantiate diagnosis, prior treatments, and rationale for therapy
Documentation should align with Ohio Administrative Code and plan contract terms

Billing Rule

Coding Inclusion Not a Guarantee of Coverage

The inclusion of procedure or drug codes in this policy is for reference only and does not imply coverage, payment, or guarantee of reimbursement. Benefit coverage is determined by federal, state, or contractual requirements and applicable laws; listing a code here is not a guarantee of coverage or payability.

Codes listed (e.g., J0881, J0882, J0885, J0887, J0888, Q4081, Q5105, Q5106) are illustrative and not exhaustive
Check member's plan and applicable laws to determine coverage and reimbursement

Background

Erythropoiesis‑stimulating agents (ESAs) such as darbepoetin alfa (Aranesp), epoetin alfa (Epogen, Procrit, Retacrit), and methoxy polyethylene glycol‑epoetin beta (Mircera) are biologic therapies that stimulate red blood cell production and are used to treat anemia related to both non‑oncology and oncology conditions. This policy addresses these specific branded and biosimilar ESAs and states that they are considered medically necessary in certain circumstances; the clinical coverage criteria that define those circumstances are found in the Ohio Department of Medicaid Unified Preferred Drug List for non‑oncology uses and in the Oncology Medication Clinical Coverage policy for cancer‑related indications.

Definitions

Definitions — Erythropoiesis‑Stimulating Agents (ESAs)

Aranespdarbepoetin alfa

Epogen / Procrit / Retacritepoetin alfa (Retacrit is epoetin alfa-epbx biosimilar)

Mirceramethoxy polyethylene glycol-epoetin beta (MPG-epoetin beta)

Initial Therapy Criteria

Initial therapy — requires meeting Ohio Medicaid Unified Preferred Drug List Criteria or Oncology policy criteria

Initial coverage requires meeting Ohio Department of Medicaid Unified Preferred Drug List Criteria for non-oncology indications or the Oncology Medication Clinical Coverage policy for oncology indications.

Initial therapy: Initiation requires meeting clinical coverage criteria defined by the Ohio Department of Medicaid Unified Preferred Drug List for non-oncology uses, or the Oncology Medication Clinical Coverage policy for oncology uses.

Continuation Therapy Criteria

Continuation therapy — ongoing medical necessity per referenced Ohio criteria or oncology policy

Continuation depends on meeting ongoing medical necessity per the referenced Ohio criteria or the Oncology Medication Clinical Coverage policy.

Continuation: Ongoing use is subject to criteria in the Ohio Department of Medicaid Unified Preferred Drug List for non-oncology indications and to the Oncology Medication Clinical Coverage (for Ohio Only) for oncology indications.

Step Therapy Requirements

Step	Requirement
1	Follow the Ohio Department of Medicaid Unified Preferred Drug List Criteria for clinical coverage of erythropoiesis‑stimulating agents (ESAs); these criteria determine step therapy requirements for non‑oncology indications. For oncology indications, refer to the Oncology Medication Clinical Coverage (for Ohio Only) policy which uses the NCCN Compendium.

Site of Care

Note

Infusion center — follow benefit plan and state/contract rules

No site-of-care (infusion center) limitations are specified in this policy; providers must follow the member's benefit plan and any applicable state or contractual rules regarding site of care.

If the benefit plan or state/contract rules impose site-of-care limits, those rules prevail.

Biosimilar Considerations

Billing Rule

Epoetin alfa (Procrit/Epogen) — Retacrit Q-codes and Ohio Medicaid placement

Retacrit (epoetin alfa-epbx) is listed with Q-codes for ESRD and non-ESRD use; follow Ohio Medicaid criteria for biosimilar placement and preferred status relative to reference epoetin alfa (Procrit/Epogen).

Q5105 = epoetin alfa-epbx (Retacrit) for ESRD on dialysis, 100 units.
Q5106 = epoetin alfa-epbx (Retacrit) for non-ESRD use, 1000 units.
Follow Ohio Department of Medicaid Unified Preferred Drug List Criteria for biosimilar preference and placement.