CurrentUnitedHealthcarePolicy CSIND0066.06

Ilaris (Canakinumab) (for Indiana Only) - Medical Benefit Drug Policy

UnitedHealthcare Medical Benefit Drug Policy for Ilaris (canakinumab) that applies only to the state of Indiana and directs coverage decisions to the InterQual Specialty Rx Non-Oncology Canakinumab criteria. Includes applicable HCPCS code reference and policy history.

Policy Summary

PayerUnitedHealthcare

PolicyIlaris (Canakinumab) (for Indiana Only) - Medical Benefit Drug Policy

Policy CodePolicy CSIND0066.06

Change TypeRoutine reviewno content changes

Effective DateNov 1, 2025

Next Review Date

Key ActionProviders must document that the patient's condition and prior therapy meet the requirements of the current InterQual CP: Specialty Rx Non-Oncology, Canakinumab (Ilaris) guideline; coverage decisions are made based on that InterQual criteria.

SourceLink

POLICY UPDATE CHANGES

Routine review; no content changes.

1Applicable HCPCS codes listed

Indiana-onlyGeographic scope

InterQualClinical criteria source

Coverage Summary

Coverage Rationale (delegated to InterQual criteria)

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Geographic scope: Patient is within the state of Indiana (policy applies only to Indiana).
Applies only to Indiana as stated in the policy application.
Clinical criteria delegation: Clinical criteria are met as specified in the current InterQual guideline: CP: Specialty Rx Non-Oncology, Canakinumab (Ilaris).
Refer to InterQual for specific indication-level criteria (e.g., diagnoses, prior therapy, dosing, monitoring).

ref": "b0_0

title": "Coverage Rationale (delegated to InterQual criteria)

This policy applies only to UnitedHealthcare Community Plan members in the state of Indiana and covers Ilaris (canakinumab) under the Medical Benefit Drug Policy for Indiana.

Medical necessity determinations are delegated to InterQual; coverage is covered_with_criteria and follows the InterQual CP: Specialty Rx Non-Oncology, Canakinumab (Ilaris) guideline as the decision source.

Provider Actions & Prior Authorization

Prior Authorization

Coverage requires InterQual criteria review

Providers must document that the patient’s condition and prior therapy meet the requirements of the current InterQual CP: Specialty Rx Non-Oncology, Canakinumab (Ilaris) guideline. Coverage decisions will be made based on that InterQual criteria.

J0638

Documentation Required

Indiana-only applicability

Confirm the patient is covered under a UnitedHealthcare Community Plan in Indiana when applying this policy; the policy applies only to the state of Indiana.

Background & Definitions

This Medical Benefit Drug Policy delegates specific medical necessity determinations for Ilaris (canakinumab) to the InterQual CP: Specialty Rx Non-Oncology guideline. UnitedHealthcare may use third‑party tools such as InterQual to assist in administering benefits and making coverage determinations.

The policy is provided to assist interpretation of UnitedHealthcare standard benefit plans but may be superseded by federal, state, or contractual requirements; in the event of a conflict, those requirements govern. The policy is Indiana‑only in application.

InterQual: A third‑party clinical criteria resource used by UnitedHealthcare to determine medical necessity for specialty medications, specifically CP: Specialty Rx Non‑Oncology, Canakinumab (Ilaris) for this policy.