CurrentUnitedHealthcarePolicy CSOH2O2500023.C

Lemtrada (Alemtuzumab) (for Ohio Only)

Defines UnitedHealthcare's medical benefit drug policy for Lemtrada (alemtuzumab) as applicable only to the state of Ohio; indicates that medical necessity determinations will reference the InterQual guideline and Ohio Administrative Code.

Policy Summary

PayerUnitedHealthcare

PolicyLemtrada (Alemtuzumab) (for Ohio Only)

Policy CodePolicy CSOH2O2500023.C

Change TypeRoutine reviewno content changes

Effective DateJun 1, 2025

Next Review Date

Key ActionProviders must have requests for Lemtrada evaluated against the current InterQual guideline 'CP: Specialty Rx Non-Oncology, Alemtuzumab (Lemtrada)' and supply documentation demonstrating compliance with Ohio Administrative Code 5160-1-01 when requested.

SourceLink

POLICY UPDATE CHANGES

Routine review performed on 2025-06-01 with no content changes.

1HCPCS code listed

OhioState scope

Medical Necessity Criteria

Medical necessity

Coverage is determined by meeting the clinical criteria in the current InterQual guideline for alemtuzumab (Lemtrada) and compliance with Ohio Administrative Code:

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What Providers Must Do

Prior Authorization

Medical necessity review using InterQual

Providers must obtain medical necessity review of Lemtrada (alemtuzumab) requests against the current InterQual guideline titled "CP: Specialty Rx Non-Oncology, Alemtuzumab (Lemtrada)"; coverage is contingent on meeting those InterQual criteria and applicable Ohio Administrative Code requirements.

J0202

Documentation Required

Reference to state regulations

Be prepared to supply documentation demonstrating compliance with Ohio Administrative Code 5160-1-01 when the service is otherwise unproven or is subject to coverage or quantity limits; UnitedHealthcare will evaluate such requests using OAC 5160-1-01 as applicable.

Clinical & Administrative Context

This policy delegates detailed clinical coverage criteria for Lemtrada (alemtuzumab) to the current InterQual guideline titled CP: Specialty Rx Non-Oncology, Alemtuzumab (Lemtrada), which UnitedHealthcare may use to assist in medical necessity determinations for the drug. UnitedHealthcare also relies on third-party tools such as InterQual to assist in administering benefit determinations while reserving final coverage decisions to the terms of the applicable benefit plan.

Where applicable, determinations will defer to state requirements under the Ohio Administrative Code 5160-1-01 and any federal or contractual requirements that govern coverage. Routine policy maintenance was performed on June 1, 2025; the prior policy version CSOH2O24D0023.B was archived with no content changes.

At-a-Glance

Policy Overview

Scope SummaryDefines UnitedHealthcare's medical benefit drug policy for Lemtrada (alemtuzumab) as applicable only to the state of Ohio; indicates that medical necessity determinations will reference the InterQual guideline and Ohio Administrative Code.

Coverage Stancecovered_with_criteria

Policy SubjectLemtrada (alemtuzumab) medical benefit drug policy (Ohio only)

Policy NumberCSOH2O2500023.C

StatusCURRENT