CurrentUnitedHealthcarePolicy CSOH2025D0088.C

Intravenous Iron Replacement Therapy (Feraheme, Injectafer & Monoferric) — Ohio

Defines UnitedHealthcare Community Plan medical benefit coverage rules for specified intravenous iron products for members in Ohio, and indicates use of InterQual criteria to determine medical necessity. Applies to providers requesting intravenous iron replacement for covered members in Ohio.

Policy Summary

PayerUnitedHealthcare

PolicyIntravenous Iron Replacement Therapy (Feraheme, Injectafer & Monoferric) — Ohio

Policy CodePolicy CSOH2025D0088.C

Change TypeAdministrative — no material clinical changes

Effective DateMar 1, 2025

Next Review Date

Key ActionSubmit prior authorization requests and supporting documentation to demonstrate medical necessity per the current InterQual Specialty Rx Non‑Oncology criteria for the requested intravenous iron product.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3products governed

3products excluded

4codes listed

OHstate

Coverage Criteria

Medical necessity per InterQual

Covered when medical necessity is met per the cited InterQual Specialty Rx Non-Oncology criteria for each product

InterQual-based coverage: Coverage for Injectafer, Feraheme, and Monoferric requires meeting the current InterQual criteria referenced for each product (Injectafer: Ferric carboxymaltose; Feraheme: Ferumoxytol; Monoferric: Ferric derisomaltose).

Providers must refer to InterQual Specialty Rx Non-Oncology guidelines for detailed clinical entry and continuation criteria.

Products excluded from this policy's criteria

Not governed by this policy (use alternative coverage rules or products)

Excluded products from these criteria: Infed (iron dextran), Ferrlecit (sodium ferric gluconate), and Venoferr (iron sucrose) are not subject to the coverage criteria in this section.

These products are explicitly listed as not subject to the InterQual-based criteria in this policy.

Policy Summary

PayerUnitedHealthcare

PolicyIntravenous Iron Replacement Therapy (Feraheme, Injectafer & Monoferric) — Ohio

Policy CodePolicy CSOH2025D0088.C

Change TypeAdministrative — no material clinical changes

Effective DateMar 1, 2025

Next Review Date

SourceLink

On This Page

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The following intravenous iron preparations are not subject to the coverage criteriaInfed (iron dextran), Ferrlecit (sodium ferric gluconate complex), and Venoferr (iron sucrose). Requests for these products should be evaluated using their applicable benefit rules or alternative coverage policies rather than the InterQual-based criteria referenced for Injectafer, Feraheme, and Monoferric.

Initial Therapy

Initial therapy

Initial coverage decisions are based on the InterQual entry criteria for each product.

InterQual initial: Initial authorization requires meeting InterQual entry criteria for the respective intravenous iron product.

Refer to the current InterQual Specialty Rx Non-Oncology guidelines listed in the policy.

Continuation Therapy

Continuation therapy

Continuation/ongoing therapy is determined by InterQual continuation criteria for each specific product.

InterQual continuation: Continued coverage requires meeting InterQual continuation criteria for the respective agent.

Refer to InterQual Specialty Rx Non-Oncology for details.

Coding / Procedure Codes

Applicable HCPCS/J-codes and Q-codesHCPCS

J1437	Injection, ferric derisomaltose, 10 mg.
J1439	Injection, ferric carboxymaltose, 1 mg.
Q0138	Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-ESRD use).
Q0139	Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for ESRD on dialysis).

Provider Actions & Prior Authorization

Prior Authorization

InterQual-based prior authorization

Prior authorization/medical necessity determinations for Injectafer (ferric carboxymaltose), Feraheme (ferumoxytol), and Monoferric (ferric derisomaltose) will be evaluated using the current InterQual clinical criteria referenced by UnitedHealthcare. Providers should submit requests through the plan's prior authorization process and reference the applicable InterQual guideline for the specific product being requested.

Affected products: Injectafer, Feraheme, Monoferric
Use current InterQual guideline for the specific product

Denial Risk

Denial risk if InterQual criteria not met

Requests for intravenous iron products that do not meet the referenced InterQual medical necessity criteria may be denied. Providers should anticipate denial risk when documentation or clinical information does not align with InterQual requirements.

Denial may occur if InterQual criteria are not met
Ensure clinical documentation supports criteria being requested

Documentation Required

Documentation and governance

When deciding coverage, providers must reference applicable federal requirements, state requirements (including the Ohio Administrative Code), and any contractual plan provisions, as those requirements govern in the event of a conflict with this policy. Maintain and submit complete clinical documentation that supports the InterQual criteria being applied (diagnoses, labs, prior therapies, treatment rationale). This policy is informational and does not replace applicable legal or contractual terms.

Reference federal, state (OAC), and contractual requirements — they govern in conflicts
Document diagnosis, relevant labs, prior oral/IV iron trials, and rationale for IV iron selection

Step Therapy

Step therapy

There are no additional explicit step therapy requirements beyond the evaluation using InterQual criteria; coverage decisions will follow the InterQual pathway which may include requirements related to prior therapies or trials as specified in the InterQual guideline for the product.

No separate UnitedHealthcare step therapy specified — follow InterQual-specified prior therapy requirements if present

Step Therapy

Step	Requirement / Notes
1	No explicit step therapy sequence is specified in this policy. Coverage and sequencing of Injectafer (ferric carboxymaltose), Feraheme (ferumoxytol), and Monoferric (ferric derisomaltose) will be determined by meeting the current InterQual Specialty Rx Non‑Oncology medical necessity criteria referenced for each product.

Site of Care

Note

No site-of-care restriction in policy — apply plan and InterQual guidance

This policy does not specify site-of-care restrictions; standard benefit plan site rules and the InterQual guidance should be applied when determining infusion location (e.g., infusion center).

Follow the member's benefit plan/site rules and InterQual recommendations for site of care.

Definitions

Injectafer — Ferric carboxymaltose (definition)

Generic nameFerric carboxymaltose

Brand nameInjectafer

Coverage ruleCovered when medical necessity is met per the current InterQual Specialty Rx Non-Oncology criteria for Ferric carboxymaltose (Injectafer).

InterQual referenceInterQual Specialty Rx Non-Oncology, Ferric carboxymaltose (Injectafer)

Feraheme — Ferumoxytol (definition)

Generic nameFerumoxytol

Brand nameFeraheme

Coverage ruleCovered when medical necessity is met per the current InterQual Specialty Rx Non-Oncology criteria for Ferumoxytol (Feraheme).

InterQual referenceInterQual Specialty Rx Non-Oncology, Ferumoxytol (Feraheme)

Monoferric — Ferric derisomaltose (definition)

Generic nameFerric derisomaltose

Brand nameMonoferric

Coverage ruleCovered when medical necessity is met per the current InterQual Specialty Rx Non-Oncology criteria for Ferric derisomaltose (Monoferric).

InterQual referenceInterQual Specialty Rx Non-Oncology, Ferric derisomaltose (Monoferric)

Background

Intravenous iron preparations such as ferumoxytol (Feraheme), ferric carboxymaltose (Injectafer), and ferric derisomaltose (Monoferric) are used to treat iron deficiency anemia when oral iron is inadequate or not tolerated. Coverage for these agents under the UnitedHealthcare Community Plan medical benefit in Ohio is determined by meeting the current InterQual Specialty Rx Non‑Oncology medical necessity criteria specific to each product. Providers must refer to the listed InterQual guideline for product‑specific entry and continuation requirements when requesting authorization.