CurrentUnitedHealthcarePolicy CSOH2025D0023.C

Lemtrada (Alemtuzumab) (for Ohio Only)

UnitedHealthcare Ohio Medical Benefit Drug Policy governing coverage and medical necessity determination for Lemtrada (alemtuzumab) for members in Ohio; applies to providers requesting authorization for this drug under Ohio plans.

Policy Summary

PayerUnitedHealthcare

PolicyLemtrada (Alemtuzumab) (for Ohio Only)

Policy CodePolicy CSOH2025D0023.C

Change TypeRoutine review (no material changes)

Effective DateJun 1, 2025

Next Review Date

Key ActionSubmit prior authorization requests demonstrating the patient meets the current InterQual guideline for alemtuzumab (Lemtrada).

SourceLink

POLICY UPDATE CHANGES

Routine review; no content changes.

J0202HCPCS code listed

OhioPolicy state

InterQualClinical criteria

1Related policies

Coverage Criteria for Lemtrada (alemtuzumab)

Initial and ongoing coverage

Policy Summary

PayerUnitedHealthcare

PolicyLemtrada (Alemtuzumab) (for Ohio Only)

Policy CodePolicy CSOH2025D0023.C

Change TypeRoutine review (no material changes)

Effective DateJun 1, 2025

Next Review Date

Key ActionSubmit prior authorization requests demonstrating the patient meets the current InterQual guideline for alemtuzumab (Lemtrada).

SourceLink

On This Page

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Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization and medical necessity determinations for Lemtrada (alemtuzumab) must follow the current InterQual® guideline. All prior authorization requests should reference the applicable InterQual® guideline (CP: Specialty Rx Non-Oncology, Alemtuzumab) and be associated with that guideline release.

Prior authorization required and determined per current InterQual® criteria
Requests should link to the specific InterQual® guideline release

Step Therapy

Step Therapy Determined by InterQual®

Step therapy requirements, when applicable, are determined by the current InterQual® criteria. There are no separate UnitedHealthcare step-therapy rules outside of the InterQual® guideline for this therapy; providers should follow the step sequence and prerequisites as specified in InterQual®.

Follow InterQual® for any step-therapy sequencing or prerequisites
No additional UnitedHealthcare step-therapy rules for Lemtrada beyond InterQual®

Documentation Required

Documentation and Governing Requirements

When making coverage determinations, providers must reference and comply with federal, state (Ohio Administrative Code), or contractual requirements for the member's benefit plan. If there is a conflict between this policy and applicable federal, state (OAC), or contractual requirements, the federal, state (OAC), or contractual requirements govern.

Verify member coverage using federal, state (OAC), and contractual terms before submitting requests
In conflicts, federal/state/contractual requirements supersede this policy

Denial Risk

Denial Risk if InterQual® Criteria Not Met

Requests that do not meet the current InterQual® criteria for medical necessity may be denied as not medically necessary. Providers should ensure documentation explicitly addresses the InterQual® criteria elements to reduce risk of denial.

Incomplete or nonconforming documentation relative to InterQual® increases denial risk
Attach clinical records demonstrating how the InterQual® criteria are met

Background

Alemtuzumab (Lemtrada) is a specialty injectable disease-modifying therapy addressed by the InterQual clinical criteria. UnitedHealthcare relies on the current InterQual guideline — CP: Specialty Rx Non‑Oncology, Alemtuzumab (Lemtrada) — to define clinical eligibility and medical necessity for initial and ongoing therapy. Refer to the InterQual release linked in the policy for the specific clinical criteria used to determine coverage.

Definitions and Clinical Reference

InterQual guideline reference — CP: Specialty Rx Non-Oncology, Alemtuzumab (Lemtrada)

InterQual guideline titleCP: Specialty Rx Non-Oncology, Alemtuzumab (Lemtrada)

PurposeServes as the clinical coverage guideline used to determine medical necessity for Lemtrada (alemtuzumab)

Coverage linkageCoverage (initial and continuation) is approved only when ALL InterQual criteria for alemtuzumab (Lemtrada) are met

Reference accessRefer to the current release of the InterQual guideline for Lemtrada for detailed eligibility and clinical criteria

Policy roleUnitedHealthcare defers to the InterQual guideline for specific clinical eligibility and medical necessity determinations for Lemtrada

Initial Therapy

Initial therapy approval is determined by the InterQual guideline.

Initial therapy per InterQual: Patient meets initial use criteria in the current InterQual CP: Specialty Rx Non-Oncology, Alemtuzumab (Lemtrada) guideline

See the InterQual release for explicit eligibility requirements for initiation of therapy

Continuation Therapy

Continuation therapy coverage follows InterQual criteria and clinical judgment.

Continuation per InterQual: Continuation approval requires continued compliance with the current InterQual criteria for alemtuzumab and applicable benefit rules

Refer to InterQual for specifics and apply clinical judgment and applicable federal, state, or contractual requirements

Site of Care Considerations

Note

Consider federal, Ohio OAC, or contractual site-of-care requirements (no specified site)

Site-of-care and coverage determinations (including infusion center use) must consider applicable federal, state (OAC), or contractual requirements; this policy does not specify or restrict a particular site of care.

Confirm whether member-specific contractual or Ohio OAC requirements impose site restrictions before scheduling infusion services.
Policy is informational and does not itself mandate an infusion center requirement.

OpenPayer