CurrentViva HealthPolicy IC-0109

Rituximab (Riabni®, Rituxan®, Ruxience®, Truxima®) coverage

Defines prior authorization, dosing limits, renewal rules, and initial approval criteria for intravenous/intrathecal/intraventricular rituximab products for oncology and non-oncology indications for Viva Health members.

Policy Summary

PayerViva Health

PolicyRituximab (Riabni®, Rituxan®, Ruxience®, Truxima®) coverage

Policy CodePolicy IC-0109

Change TypeNo material change

Effective Date

Next Review DateApr 1, 2026

Key ActionObtain prior authorization documenting contraindication/intolerance/failure to Riabni, Ruxience, AND Truxima and include an appropriate Appendix 1 ICD-10 diagnosis code.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsinitial PA validity

180 daysrenewal interval

requiredHBV screening

4HCPCS codes listed

100-780per-dose unit range

Coverage Criteria and Indications

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

inv-01: Initial Approval

Prior authorization validity is provided when ALL of the following are met:

Initial approval requirements: Patient must have a documented contraindication, intolerance, or failure to Riabni®, Ruxience®, AND Truxima® prior to consideration of another rituximab product

Document prior trials of listed rituximab products

Age requirement: Member is at least 18 years of age unless an indication-specific criterion specifies a different minimum age>= 18 years unless specified

See pediatric indication sections for exceptions

inv-02: Prior Authorization Validity and Renewal

Prior authorization validity and renewal constraints differ by indication:

Oncology initial/renewal validity: Initial prior authorization validity for oncology indications is generally 180 days (6 months); renewals may be provided every 180 days for up to a maximum of 2 years unless otherwise specified (exceptions and per-indication limits apply)180 days initial; renew every 180 days up to 2 years unless specified

See Section I for oncology exceptions

Non-oncology initial/renewal validity: Initial prior authorization validity for non-oncology indications is generally 180 days (6 months) unless otherwise specified; certain non-oncology indications (Pemphigus Vulgaris, Systemic Lupus Erythematosus, Lupus Nephritis) have initial validity of 12 months (365 days); renewals are generally every 180 days thereafter unless indicated otherwise180 days initial (365 days for specified non-oncology indications)

See Section I for list of non-oncology exceptions

inv-03: Initial Approval Criteria (general)

Covered when ALL of the following are met:

Universal prior auth prerequisites: Member has documented contraindication, intolerance, or failure to Riabni®, Ruxience®, AND Truxima®; AND member meets any indication-specific age requirement

Document prior trials and age eligibility

Safety screening requirements: No severe active infection; member screened for hepatitis B (HBsAg and anti-HBc) prior to initiating therapy with monitoring for reactivation when indicated; no live vaccine within 28 days prior to starting therapy and avoid live vaccines during treatment

HBV screening and vaccine timing required per Universal Criteria

Oncology CD20 requirement: For oncology indications (unless specifically excluded), member is CD20 antigen expression positive

Exclusions listed for cGVHD, HCT, TA-TMA, KSHV-associated syndromes, and ICI-toxicity uses

inv-04: Pediatric Indications

Covered when ALL of the following age- and disease-specific criteria are met:

Pediatric mature B-cell acute leukemia: Member is at least 6 months of age AND rituximab is used in combination with chemotherapy for previously untreated disease>= 6 months

Pediatric dosing and regimen per pediatric oncology protocols

Pediatric aggressive mature B-cell lymphomas: Member is at least 6 months of age AND rituximab is used with chemotherapy for specified histologies (e.g., primary mediastinal large B-cell lymphoma, DLBCL, Burkitt) or for PTLD prevention/treatment with documented EBV reactivation where applicable>= 6 months

AYA exceptions may apply up to age 39 when treated in pediatric setting

Pediatric Hodgkin lymphoma: Member is ≤ 18 years of age (AYA exceptions noted) with nodular lymphocyte-predominant disease AND rituximab used in combination with CVbP as primary therapy for stage IA or IIA incomplete resection non-bulky disease

inv-05: Transplant Associated-Thrombotic Microangiopathy (TA-TMA)

Covered for TA-TMA when ALL apply:

Post-transplant status: Member is post-hematopoietic stem cell transplant (HSCT)

No minimum age requirement for TA-TMA indication

Alternative diagnoses excluded: Alternative diagnoses (e.g., TTP, Coombs-positive hemolytic anemia, medication toxicities, infections, DIC, GVHD) have been excluded

Clinical workup must exclude other causes

High-risk disease features (any one): Random urine protein to creatinine ratio (rUPCR) ≥ 1 OR elevated serum sC5b-9 > upper limit of normal OR LDH ≥ 2 × ULN OR concurrent grade II–IV acute GVHD OR concurrent bacterial or viral infection OR clinical evidence of TA-TMA–related organ dysfunction (excluding KDIGO stage I AKI)rUPCR >=1; sC5b-9 > ULN; LDH >=2x ULN

At least one high-risk feature required

inv-06: Immune Checkpoint Inhibitor-Related Toxicities

Covered as additional therapy for specified ICI-related toxicities when criteria below are met:

Encephalitis (ICI-related): Member receiving an immune checkpoint inhibitor has encephalitis related to immunotherapy AND is autoimmune-encephalopathy-antibody positive OR has had limited/no improvement after 7–14 days on high-dose corticosteroids with or without IVIG7–14 days of high-dose corticosteroids without improvement

Use as additional therapy when steroid-refractory or antibody-positive

Bullous dermatitis (ICI-related): Bullous dermatitis related to immunotherapy used as additional therapy for severe (G3) or life‑threatening (G4) diseaseGrade G3–G4 severity

Per ICI-toxicity grading

Bullous pemphigoid (ICI-related): Biopsy- or serology-confirmed bullous pemphigoid related to immunotherapy used as additional therapy for moderate (G2) disease

inv-07: Selected Oncology Indications and Regimen Requirements

Covered for listed hematologic and related malignancies when indication-specific combination/regimen and disease features are met (select items):

Adult ALL: For Philadelphia chromosome–positive (Ph+) disease, used in combination with MOpAD for TKI‑refractory disease OR for Ph‑ disease as a component of multiagent chemotherapy; member selection per NCCN guidance

Refer to Adult ALL section for regimen specifics

Primary CNS lymphoma / leptomeningeal metastases: Allowed as intra‑CSF for leptomeningeal metastases OR as induction/relapsed therapy/systemic IV or intra‑CSF for PCNSL with allowed combination agents or consolidation as specified

Intra‑CSF or systemic use per CNS cancers criteria

CLL/SLL regimen options: Multiple allowed regimens including combination with fludarabine+cyclophosphamide; first‑line with bendamustine if no del(17p)/TP53 and BTK/BCL2 inhibitors not available; subsequent therapy options include bendamustine, idelalisib, lenalidomide, venetoclax; specific allowances for del(17p)/TP53 scenarios

Regimen selection depends on mutation status and prior therapies

inv-08: Management of Immune Checkpoint Inhibitor-Related Toxicities

Covered when ANY of the following ICI-related toxicity scenarios are met:

ICI-related encephalitis: Member receiving an immune checkpoint inhibitor has encephalitis related to immunotherapy AND (is autoimmune‑encephalopathy‑antibody positive OR has had limited/no improvement after 7–14 days on high‑dose corticosteroids with or without IVIG)7–14 days without improvement

From ICI‑toxicity management criteria

Bullous dermatitis: Member has bullous dermatitis related to immunotherapy AND used as additional therapy for severe (G3) or life‑threatening (G4) diseaseGrade G3–G4

From ICI‑toxicity management criteria

Bullous pemphigoid: Member has biopsy‑ or serology‑confirmed bullous pemphigoid related to immunotherapy AND used as additional therapy for moderate (G2) disease

inv-09: Rheumatoid Arthritis (RA)

Covered when ALL of the following are met:

RA baseline and severity: Physician has assessed baseline disease severity using an objective tool AND documented moderate to severe active disease

Objective assessment and documentation required

Combination with methotrexate: Rituximab used in combination with methotrexate unless contraindication or intolerance is documented

Combination therapy expected unless contraindicated

Prior csDMARD trial: Member tried and failed at least a 3‑month trial with ONE conventional synthetic DMARD OR is already established on biologic/targeted synthetic therapy3 months

3‑month csDMARD trial required unless already on biologic/targeted therapy

inv-10: Pemphigus Vulgaris

Covered when ALL of the following are met:

Diagnostic confirmation: Clinical features consistent with pemphigus vulgaris AND histopathologic confirmation by biopsy AND positive direct immunofluorescence (DIF) OR autoantibodies detected by IIF/ELISA

Biopsy and serology required for diagnosis confirmation

Disease severity: Member has moderate to severe disease as assessed with an objective tool (e.g., PDAI, PSS, ABSIS)

Objective severity assessment required

Combination with glucocorticoids: Rituximab used in combination with glucocorticoids

Concurrent steroid therapy expected

Exclude other causes: Other causes of blistering/erosive disease have been ruled out

inv-11: Granulomatosis with Polyangiitis (GPA) and Microscopic Polyangiitis (MPA)

Covered when ALL of the following are met:

Age: Member is at least 2 years of age>= 2 years

Applies to GPA and MPA indications

Induction or maintenance use: Used as induction therapy in combination with glucocorticoids OR used as maintenance therapy with or without glucocorticoids

Both induction and maintenance uses allowed per clinical scenario

inv-12: Thrombocytopenic Purpura

Covered when ALL of the following are met:

Diagnosis includes primary thrombocytopenia/ITP or Evans syndrome

Document diagnosis per clinical records

Prior steroid failure or intolerance: Member has previously failed or has a contraindication or intolerance to corticosteroids

Steroid failure/intolerance must be documented

Bleeding risk platelet threshold: Member is at increased risk for bleeding as indicated by platelet count within previous 28 days < 30 × 10^9/L (30,000/mm³)<30,000/mm3

Recent platelet count required to support bleeding risk

inv-13: Thrombotic Thrombocytopenic Purpura (TTP)

Covered when ALL of the following are met:

ADAMTS13-deficiency: Member has immune‑mediated or acquired TTP with ADAMTS13 deficiency

Laboratory confirmation of ADAMTS13 deficiency required

Use with therapeutic plasma exchange (TPE): Used in combination with corticosteroids and therapeutic plasma exchange OR used as single agent as prophylactic therapy for members in remission

Therapeutic context specified

inv-14: Multiple Sclerosis (MS)

Covered when ALL of the following are met:

Confirmed MS diagnosis: Member has confirmed diagnosis of MS documented by appropriate laboratory/imaging reports (e.g., MRI)

Relapsing forms only (RRMS, active SPMS, CIS)

Relapsing form requirement: Member has a relapsing form of MS (relapsing‑remitting MS, active secondary progressive MS, or clinically isolated syndrome)

Indication limited to relapsing forms

inv-15: Autoimmune Hemolytic Anemia (AIHA)

Covered when ANY of the following are met:

Warm‑reactive AIHA: Member has warm‑reactive autoimmune hemolytic anemia refractory to or dependent on glucocorticoids

Warm AIHA refractory/dependent on steroids qualifies

Cold agglutinin disease: Member has cold agglutinin disease with symptomatic anemia, transfusion dependence, and/or disabling circulatory symptoms

Cold agglutinin disease with significant clinical impact qualifies

inv-16: Systemic Lupus Erythematosus (SLE) — non-LN

Covered when ALL of the following are met:

Active SLE without LN: Member has active systemic lupus erythematosus WITHOUT active lupus nephritis

SLE without LN required for this criteria set

Hydroxychloroquine trial or intolerance: Member has tried and had inadequate response to hydroxychloroquine OR has intolerance/hypersensitivity OR has FDA‑labeled contraindication to hydroxychloroquine

Trial or intolerance to hydroxychloroquine required

Corticosteroid/immunosuppressive trial: Member has tried and had inadequate response to ONE corticosteroid OR immunosuppressive agent OR has intolerance/hypersensitivity OR has FDA‑labeled contraindication to all corticosteroids and immunosuppressive agents

Prior trial(s) of steroids or immunosuppressives required unless contraindicated

inv-17: Lupus Nephritis (LN)

Covered when ALL of the following are met:

Active LN with biopsy class: Member has active lupus nephritis with class III, IV, or V disease confirmed via kidney biopsyClass III/IV/V

Renal biopsy confirmation required

Background LN therapy: Member will be using background immunosuppressive LN therapy (e.g., corticosteroids plus mycophenolate, azathioprine, or cyclophosphamide)

Background therapy expected

No severe CNS lupus: Member does not have severe active CNS lupus

Severe CNS lupus exclusion applies

Combination therapy rules:

inv-18: Myasthenia Gravis (MuSK-positive)

Covered when ALL of the following are met:

MuSK antibody positive: Member has MuSK‑antibody positive myasthenia gravis

Serologic confirmation required

Refractory disease: Member is refractory to standard first‑line therapy (e.g., glucocorticoids, azathioprine, mycophenolate mofetil)

Refractoriness to first‑line agents must be documented

inv-19: Complications of Transplanted Solid Organ

Covered when ANY of the following transplant-related indications are met:

Pre-transplant HLA suppression: Used for suppression of panel reactive anti‑HLA antibodies prior to transplantation

No minimum age requirement for transplant‑related indications

Antibody-mediated rejection: Used for treatment of antibody‑mediated rejection of solid organ transplantation

Supports treatment of AMR in solid organ transplants

inv-20: Neuromyelitis Optica Spectrum Disorder (NMOSD)

Covered when ALL of the following are met:

AQP4 seropositive criteria: Member is seropositive for AQP4‑IgG AND has at least one core clinical characteristic AND alternative diagnoses excluded

Seropositive pathway requires one core clinical characteristic

AQP4 seronegative/unknown criteria: If seronegative or unknown, member must have at least two core clinical characteristics from one or more attacks, including at least one of acute optic neuritis, acute myelitis, or area postrema syndrome, AND typical MRI findings for affected areas AND alternative diagnoses excluded

Seronegative pathway requires additional clinical and MRI criteria

Use with immunosuppression: Used as single agent or in combination with immunosuppressive therapy (e.g., azathioprine, methotrexate, mycophenolate)

Combination therapy allowed

inv-21: Antisynthetase Syndrome-Related Interstitial Lung Disease

Covered when ALL of the following are met:

Antisynthetase antibody positive: Member has antisynthetase antibody positive disease (e.g., anti‑Jo‑1, ‑PL‑7, ‑PL‑12, ‑OJ, ‑EJ)

Serologic confirmation required

Baseline severity assessment: Physician has assessed baseline disease severity using objective measures (baseline glucocorticoid use, PFTs [FVC%, TLC%, DLCO%], or chest CT)

Objective baseline measures required

Severe and refractory disease: Member has documented severe active disease and recurrent or progressive disease despite glucocorticoids and/or other immunosuppressive agents

Refractory disease after standard therapies required

Combination therapy:

inv-22: Idiopathic (Primary) Membranous Nephropathy

Covered when ANY of the following are met (first-line or relapse/resistance scenarios):

First-line with high‑risk features: Used as first‑line therapy in members with moderate to high risk factors for progressive idiopathic membranous nephropathy: proteinuria >3.5 g/day with no >50% decrease after 6 months ACEi/ARB OR eGFR <60 ml/min/1.73m2 OR proteinuria >8 g/day for >6 months OR serious nephrotic complicationsproteinuria/eGFR thresholds specified

Secondary causes must be ruled out prior to labeling as primary MN

Initial relapse: Used for initial disease relapse following remission on first‑line therapy with rituximab, a calcineurin inhibitor, or cyclophosphamide plus glucocorticoids

Relapse after prior remission qualifies

Treatment resistance: Used for treatment‑resistance to first‑line therapy with rituximab, a calcineurin inhibitor, or cyclophosphamide plus glucocorticoids; additional conditions include stable eGFR when applicable and combination with a calcineurin inhibitor if previously treated with rituximab alone

inv-23: Antisynthetase Syndrome-Related Interstitial Lung Disease

Covered when ALL of the following are met

Antisynthetase ILD criteria (duplicate): Member has antisynthetase antibody positive disease; physician has assessed baseline severity using objective measures; member has severe active disease despite glucocorticoids and/or other immunosuppressive agents; will be used in combination with glucocorticoids or other immunosuppressive agents unless contraindicated

Duplicate of Antisynthetase ILD criteria

inv-24: Idiopathic (Primary) Membranous Nephropathy

Covered when ANY of the following first-line/high-risk or relapse/resistant criteria are met (with additional conditions as specified)

Primary MN baseline: Documented idiopathic (primary) membranous nephropathy AND secondary causes ruled out

Secondary causes must be excluded

First‑line high‑risk features: Any of: proteinuria >3.5 g/day with <50% reduction after 6 months ACEi/ARB; eGFR <60 ml/min/1.73m2; proteinuria >8 g/day for >6 months; serious nephrotic complicationsproteinuria/eGFR thresholds per policy

High‑risk features justify first‑line use

Relapse or treatment‑resistance: Initial relapse after remission on first‑line therapy OR treatment resistance to first‑line therapies; additional conditions: stable eGFR when applicable AND combine with calcineurin inhibitor if previously treated with rituximab alone; also covered for post‑transplant recurrence with proteinuria >1 g/day

Conditions for retreatment and post‑transplant recurrence specified

inv-25: Pediatric Idiopathic Nephrotic Syndrome

Covered when ALL of the following are met

Pediatric idiopathic nephrotic syndrome criteria: Member is ≤ 12 years of age AND has symptomatic nephrotic‑range disease AND diagnosed with FRNS, SDNS, or SRNS per definitions AND has failed an adequate trial with at least one other steroid‑sparing agent (e.g., cyclophosphamide, calcineurin inhibitor, mycophenolate)age ≤12

Definitions for FRNS/SDNS/SRNS provided in policy

inv-26: IgG4-Related Disease

Covered when ALL of the following are met:

Confirmed IgG4‑RD diagnosis: Member has confirmed IgG4‑related disease with supporting exam, imaging, labs, or pathology AND other mimicking conditions ruled out

Diagnostic confirmation required

Steroid‑refractory or intolerant disease: Member is experiencing an IgG4‑RD flare that required corticosteroids AND disease is refractory to corticosteroids OR member has contraindication/intolerance to corticosteroids

Steroid‑refractory or contraindication required

High risk of recurrent flares: Member is at high risk of recurrent disease flares based on history of disease in ≥2 organs/sites AND at least one specified organ is affected (e.g., pancreas, bile ducts, orbits, lungs, kidneys, salivary glands, retroperitoneum, aorta, pachymeninges, sinonasal tract, thyroid)≥2 organs/sites

High‑risk multi‑organ involvement required

inv-27: Wiskott-Aldrich Syndrome (pre-treatment)

Covered when ANY of the following pre-treatment purposes are met

Wiskott‑Aldrich pretreatment: Used as pretreatment prior to infusion of etuvetidigene autotemcel to deplete autoreactive B‑cells OR as pre‑emptive treatment for potential EBV‑related lymphoproliferative disorder

Pre‑treatment role prior to gene therapy infusion

inv-28: Oncology Indications / Treatment Response

Renewal/continuation requires evidence of treatment response or disease stabilization

Adult ALL response: Treatment response or stabilization as indicated by CBC, bone marrow cytogenetic analysis, QPCR, or FISH

Oncology response measures required for renewal

Other oncology response: Disease response defined as stabilization or decrease in tumor size or spread

Objective oncology response required for renewal

inv-29: Rheumatoid Arthritis (renewal/continuation)

Covered when ALL of the following are met

RA renewal/continuation criteria: Disease response indicated by improvement in signs/symptoms vs baseline (tender/swollen joint counts, CRP, patient global assessment) and/or validated disease activity tools (e.g., DAS28 improvement ≥1.2 or ≥20% ACR20, RAPID3); dose escalation allowed case‑by‑case after initial response and maintenance dosingDAS28 ≥1.2 or ACR20 ≥20% improvement

Objective improvement required for renewal/continuation

inv-30: Thrombocytopenic Purpura (ITP / Evans Syndrome)

Covered when response is achieved and maintained

ITP/Evans response: Disease response indicated by achievement and maintenance of platelet count ≥30 × 10^9/L and at least doubling of baseline platelet countplatelet ≥30 × 10^9/L and ≥2× baseline

Objective platelet response required for continuation

inv-31: Thrombotic Thrombocytopenic Purpura (TTP)

Covered when laboratory response is achieved

TTP laboratory response: Disease response indicated by increase in ADAMTS13 activity with reduction in thrombotic riskADAMTS13 activity increase

Laboratory improvement required for renewal

inv-32: Multiple Sclerosis (continuation monitoring)

Covered when ongoing monitoring shows clinical benefit

MS continuation monitoring: Continuous monitoring indicates beneficial response (e.g., decreased relapses, no new/worsening MRI lesions, stable or improved disability measures); inadequate response defined per policy criteriaas defined in policy

Objective monitoring required for continuation

inv-33: GPA and MPA (vasculitis)

Covered when ALL of the following are met

GPA/MPA continuation criteria: Disease response indicated by disease control and improvement in signs/symptoms vs baseline AND decreased frequency of major relapses

Clinical improvement and relapse reduction required

inv-34: Pemphigus Vulgaris

Covered when ALL of the following are met

Pemphigus continuation/relapse criteria: Member is currently receiving tapering corticosteroids or has discontinued corticosteroids AND demonstrates disease response (complete epithelialization or no new lesions with healing of established lesions) OR for relapses: previously achieved disease control and now has ≥3 new lesions/month not healing within 1 week≥3 new lesions/month for relapse criteria

Objective clinical improvement or relapse criteria required

inv-35: Autoimmune Hemolytic Anemia (AIHA)

Covered when BOTH clinical and laboratory improvement are demonstrated

AIHA continuation criteria: Disease response indicated by improvement in anemia symptoms AND improvement in laboratory values (hemoglobin/hematocrit), reduced transfusion needs, and/or reduced glucocorticoid use

Both clinical and lab improvement required for continuation

inv-36: Systemic Lupus Erythematosus (SLE) — Renewal/Continuation

Covered when continuation shows clinical benefit and adjunctive therapy maintained

SLE continuation criteria: Member has experienced clinical benefit with the requested agent AND continues standard SLE therapy (corticosteroids, hydroxychloroquine, azathioprine, methotrexate, mycophenolate, cyclophosphamide)

Continuation contingent on ongoing adjunctive therapy

inv-37: Lupus Nephritis — Renewal-specific condition

Renewal-specific condition

Lupus nephritis renewal limitation: Prior authorization may only be renewed in members experiencing disease relapse (e.g., increased serum creatinine, increased urine protein excretion, decreased eGFR)

Renewal limited to relapse events

inv-38: Systemic Lupus Erythematosus (SLE)

Covered when ALL of the following are met

SLE coverage conditions (duplicate): Member has experienced clinical benefit with the requested agent; AND member is currently treated with and will continue standard SLE therapy (e.g., corticosteroids, hydroxychloroquine, azathioprine, methotrexate, mycophenolate, cyclophosphamide)

Duplicate SLE continuation criteria captured for emphasis

inv-39: Lupus Nephritis

Covered when ALL of the following are met

Lupus nephritis renewal: Member has experienced clinical benefit with the requested agentPrior authorization validity may only be renewed in members experiencing a disease relapse (e.g., increased serum creatinine, increased protein urine excretion, decreased eGFR)

Renewal limited to relapse events

inv-40: Myasthenia Gravis

Covered when ALL of the following are met

Myasthenia gravis response: Disease response indicated by decrease in daily corticosteroid dose and/or improvement in signs and symptoms compared to baseline

Applies to myasthenia gravis unrelated to ICI toxicity

inv-41: Neuromyelitis Optica Spectrum Disorder (NMOSD)

Covered when ANY of the following disease responses are met

NMOSD response metrics: Stabilization or improvement demonstrated by decreased acute relapses, reduced hospitalizations, reduction/discontinuation in plasma exchange, or reduction/discontinuation of corticosteroids without relapse

Objective clinical or resource use improvements indicate response

inv-42: Antisynthetase Syndrome-Related ILD

Covered when ANY of the following disease responses are met

Antisynthetase ILD response: Reduction or stabilization of glucocorticoid use from baseline OR improvement/stabilization in PFTs (>10% increase FVC/TLC/DLCO for improvement; <10% decrease for stabilization) OR improvement/stabilization in chest CT score (>10% decrease improvement; <10% increase stabilization)PFT and CT thresholds as specified

Objective pulmonary function or imaging improvements qualify for continuation

inv-43: Idiopathic Membranous Nephropathy

Covered when ONE of the following is met

Idiopathic membranous nephropathy response: Member experienced beneficial disease response (e.g., reduction in proteinuria, increased/normalized serum albumin, improved/stable creatinine/eGFR, decreased anti‑PLA2R) OR member has resistant disease following first‑line rituximab; if previously treated with rituximab alone in first‑line, agent should be used in combination with a calcineurin inhibitor and member must have stable eGFR

One of these conditions required for continuation

inv-44: Pediatric Idiopathic Nephrotic Syndrome

Covered when ALL of the following are met

Pediatric idiopathic nephrotic syndrome response: Member previously achieved beneficial disease response from prior course AND member has recurrent active disease necessitating additional doses as defined by recurrent nephrotic‑range proteinuria (dipstick ≥3+ for 3 consecutive days OR UPCR ≥200 mg/mmol on 3 consecutive days)pediatric recurrence thresholds as specified

Recurrence definitions required for additional dosing

inv-45: IgG4-Related Disease

Covered when ANY of the following disease responses are met

IgG4‑RD response: Reduction in corticosteroid requirement for flares OR reduction in flares OR stabilization/improvement in symptoms, exam, imaging, labs, or pathology compared to baseline

One or more objective improvements required for continuation

inv-46: Multiple Sclerosis Maintenance Dose

Covered when dosing aligns with maintenance guidance

MS maintenance dosing: Goal maintenance dose: 500 mg IV every 12 months500 mg q12 months

Dose decrease limited to no more than 500 mg or interval increase by no more than 6 months

inv-47: Diagnosis-code-based coverage requirement

Covered when the member's diagnosis is one of the listed ICD-10 codes in Appendix 1 and clinical medical necessity criteria (elsewhere in policy)

Diagnosis match: Submission includes one ICD‑10 code from Appendix 1 corresponding to the member’s conditionexact match to Appendix 1 code

Appendix 1 provides the covered diagnosis codes; clinical criteria elsewhere must also be met

inv-48: Diagnosis must match Appendix 1

Covered when the submitted claim lists a diagnosis included in Appendix 1

Appendix 1 match: The patient diagnosis code on the claim must exactly match one of the ICD‑10 codes listed in Appendix 1 to support coverage for the related specialty drugexact match

See Appendix 1 code list for acceptable codes

inv-49: Medicare coverage guidance

For Medicare Part B beneficiaries

Medicare compliance: Medicare Part B coverage determinations follow CMS manuals and any applicable NCDs, LCDs, or LCAs; providers must comply with those for Medicare membersn/a

Appendix 2 lists MAC jurisdictions and references to NCD/LCD documents

Prior authorization validity for many indications is time-limited and, in specified situations, may not be renewed. Examples of oncology and non-oncology scenarios where initial authorization validity will NOT be renewed include multiple pediatric induction/consolidation oncology settings (e.g., pediatric B‑cell acute leukemia, pediatric aggressive mature B‑cell lymphomas, pediatric Hodgkin lymphoma), select transplant-related uses (e.g., hematopoietic cell transplantation, TA‑TMA), and certain immune checkpoint inhibitor toxicity management scenarios. Providers should plan for these limits when requesting therapy and include documentation that supports the single-course/induction use as applicable.

This policy includes indication-specific nodes for non-oncology transplant and inflammatory complications. Use of rituximab is explicitly supported for chronic graft‑versus‑host disease (cGVHD), hematopoietic cell transplantation (conditioning and peri‑transplant use), transplant associated‑thrombotic microangiopathy (TA‑TMA with high‑risk features), and KSHV‑associated inflammatory cytokine syndrome per the dosing and clinical criteria described. When requesting coverage for these indications, include the relevant transplant status, biopsy/diagnostic findings, and the objective laboratory thresholds (e.g., TA‑TMA high‑risk features) called out in the criteria.

Concurrent administration of rituximab with another CD20‑directed therapy, biologic agent, or targeted synthetic therapy is not consistent with the non‑oncology coverage criteria and may be considered not medically necessary. Providers requesting coverage must document that the member is not receiving overlapping CD20 or other biologic/targeted synthetic therapies for the same non‑oncology indication.

For idiopathic (primary) membranous nephropathy, coverage requires confirmation that secondary causes have been excluded (for example: infections, other autoimmune diseases, malignancy, dietary or herbal supplements, and NSAID exposure). Documentation that secondary etiologies were assessed and ruled out must be provided with the initial request.

Prior authorization renewal for lupus nephritis is operationally restricted: renewals are generally limited and may only be granted for members experiencing disease relapse (for example, rising serum creatinine, increased proteinuria, or declining eGFR). Requests for continued maintenance outside of documented relapse should include clear objective evidence to justify an exception.

Within the extracted criteria there are no additional, separate explicit exclusions beyond the listed non‑renewable uses and the concurrent‑therapy and secondary‑cause exceptions described; reviewers should apply the specific indication criteria and renewal rules shown rather than assume other general exclusions.

Claims and prior authorization requests must use a diagnosis that appears in Appendix 1. Diagnoses not listed in Appendix 1 are not covered under the conditions enumerated in this appendix; if the members diagnosis is not in Appendix 1, providers must reference the main policy for applicable coverage pathways or supporting documentation.

Appendix 2 clarifies that the preceding information is intended for non‑Medicare coverage determinations. For Medicare Part B beneficiaries, coverage and billing are governed by CMS policy (Medicare Benefit Policy Manual Chapter 15 §50) and any applicable NCDs, LCDs, or LCAs; providers should consult the CMS Medicare Coverage Database and the cited local coverage documents when processing Medicare claims.

Initial Therapy: Dosing and Induction Regimens

Continuation / Renewal Criteria

Step Therapy and Sequencing Requirements

Requirement	Details
Required prior trial of preferred rituximab products
Member must have a documented contraindication, intolerance, or failure to Riabni®, Ruxience®, AND Truxima® before another rituximab product will be considered for authorization.

Step requirement	Clinical expectation
Trial and failure/intolerance/contraindication to listed rituximab products
Authorization for an alternative rituximab product requires documentation that the member has trialed and failed, or is intolerant of, or has a contraindication to Riabni®, Ruxience®, AND Truxima®.

Indication group	Prior therapy required
Rheumatoid arthritis (RA)
Member must have tried and failed at least a 3-month trial of one conventional synthetic DMARD (e.g., methotrexate) or be already on biologic/targeted synthetic therapy; prior TNF antagonist failure is required per indication details.
Systemic lupus erythematosus (SLE) — non-LN
Member must have tried and had inadequate response to hydroxychloroquine (or have intolerance/contraindication) AND tried and had inadequate response to one corticosteroid or immunosuppressive agent (or have intolerance/contraindication) as specified.
Idiopathic membranous nephropathy
Secondary causes must be ruled out; prior use of ACEi/ARB for 6 months without >50% proteinuria reduction or other first-line therapies (calcineurin inhibitor, cyclophosphamide + glucocorticoids) as specified are required before CD20 therapy in many scenarios.

Population / scenario	Required prior agents
Idiopathic membranous nephropathy — first‑line high‑risk
First-line use is allowed for members with high-risk features (e.g., proteinuria >3.5 g/day with <50% reduction after 6 months ACEi/ARB, eGFR <60 mL/min/1.73 m2, or proteinuria >8 g/day >6 months), with secondary causes excluded.
Pediatric idiopathic nephrotic syndrome (≤12 years)
Member must have failed an adequate trial with at least one other steroid‑sparing agent (e.g., cyclophosphamide, calcineurin inhibitor, mycophenolate mofetil) before rituximab is authorized.

Scenario	Sequencing requirement
Resistant idiopathic membranous nephropathy after first‑line rituximab
If disease is resistant following first‑line rituximab, continued therapy should be used in combination with a calcineurin inhibitor; member must have stable eGFR per policy requirements.
Relapse or treatment‑resistant membranous nephropathy
Use is allowed for relapse following remission on first‑line therapy (rituximab, calcineurin inhibitor, or cyclophosphamide + glucocorticoids) or for treatment‑resistance to those first‑line therapies, with additional conditions as specified.

Step therapy sequence	Notes / guidance
No explicit step therapy sequence specified
The policy does not define a detailed, multi‑step sequence here; guideline and compendium references (e.g., NCCN, specialty society guidance) are provided to support clinical justification for therapy selection and sequencing.

Coding, Units, and Diagnostic Codes

HCPCS CodesHCPCSCovered

J9312	Injection, rituximab, 10 mg; 1 billable unit = 10 mg (Rituxan IV only)
Q5115	Injection, rituximab-abbs, biosimilar (Truxima), 10 mg; 1 billable unit = 10 mg
Q5119	Injection, rituximab-pvvr, biosimilar (Ruxience), 10 mg; 1 billable unit = 10 mg
Q5123	Injection, rituximab-arrx, biosimilar (Riabni), 10 mg; 1 billable unit = 10 mg

HCPCS Codes (neutral)HCPCS

No codes listed

NDC CodesNDC

50242-0051-xx	Rituxan 100 mg/10 mL single-dose vial
50242-0053-xx	Rituxan 500 mg/50 mL single-dose vial
63459-0103-xx	Truxima 100 mg/10 mL single-dose vial
63459-0104-xx	Truxima 500 mg/50 mL single-dose vial
00069-0238-xx	Ruxience 100 mg/10 mL single-dose vial
00069-0249-xx	Ruxience 500 mg/50 mL single-dose vial
55513-0224-xx	Riabni 100 mg/10 mL single-dose vial
55513-0326-xx	Riabni 500 mg/50 mL single-dose vial

Covered ICD-10 Codes (selected)ICD-10Covered

C82.12	Follicular lymphoma, grade II, intrathoracic lymph nodes
M05.611	Rheumatoid arthritis of right shoulder with involvement of other organs and systems
M05.612	Rheumatoid arthritis of left shoulder with involvement of other organs and systems
M05.619	Rheumatoid arthritis of unspecified shoulder with involvement of other organs and systems
M05.621	Rheumatoid arthritis of right elbow with involvement of other organs and systems
M05.622	Rheumatoid arthritis of left elbow with involvement of other organs and systems
M05.629	Rheumatoid arthritis of unspecified elbow with involvement of other organs and systems
M05.631	Rheumatoid arthritis of right wrist with involvement of other organs and systems
M05.632	Rheumatoid arthritis of left wrist with involvement of other organs and systems
M05.639	Rheumatoid arthritis of unspecified wrist with involvement of other organs and systems

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