Medical and Drug Policies
The Medical Policies, Medical Benefit Drug Policies, and corresponding update bulletins for UnitedHealthcare Community Plan of Indiana are listed below.
A monthly notice of recently approved and/or revised Medical Policies and Medical Benefit Drug Policies is provided below for your review. We publish a new announcement on the first calendar day of every month.
The appearance of a health service (e.g., test, drug, device, or procedure) in the Medical Policy Update Bulletin does not imply that UnitedHealthcare provides coverage for the health service. In the event of an inconsistency or conflict between the information provided in the Medical Policy Update Bulletin and the posted policy, the provisions of the posted policy will prevail.
01/01/2025 – Community Plan of Indiana Medical Policy Update Bulletin: January 2025
Last Published 01.01.2025
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Community Plan of Indiana Medical Policies and/or Medical Benefit Drug Policies.
02/01/2025 – Community Plan of Indiana Medical Policy Update Bulletin: February 2025
Last Published 02.01.2025
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Community Plan of Indiana Medical Policies and/or Medical Benefit Drug Policies.
12/01/2024 – Community Plan of Indiana Medical Policy Update Bulletin: December 2024
Last Published 12.01.2024
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Community Plan of Indiana Medical Policies and/or Medical Benefit Drug Policies.
Community Plan of Indiana Medical Policy Update Bulletin Archive
Last Published 02.01.2025
A listing of the Medical Policy Update Bulletins.
Current Policies
Community Plan of Indiana Medical & Drug Policies Terms and Conditions
Please read the terms and conditions below carefully.
UnitedHealthcare has developed Medical Policies and Medical Benefit Drug Policies to assist us in administering health benefits. These policies are provided for informational purposes and do not constitute medical advice. Treating physicians and health care providers are solely responsible for determining what care to provide to their patients. Members should always consult their physician before making any decisions about medical care.
Our Medical Policies and Medical Benefit Drug Policies express our determination of whether a health service (e.g., test, device, or procedure) is proven to be effective based on the published clinical evidence. They are also used to decide whether a given health service is medically necessary. Services determined to be experimental, investigational, unproven, or not medically necessary by the clinical evidence are typically not covered.
Benefit coverage for health services is determined by the specific benefit plan. When deciding coverage, the federal, state, or contractual requirements for benefit plan coverage must be referenced. In the event of a conflict, the federal, state, or contractual requirements for benefit plan coverage supersede these policies.
Medical Policies and Medical Benefit Drug Policies are developed as needed, regularly reviewed and updated, and subject to change. They represent a portion of the resources used to support UnitedHealthcare coverage decision making. The information presented in these policies is believed to be accurate and current as of the date of publication and is provided on an "AS IS" basis. Additionally, UnitedHealthcare may use tools developed by third parties, such as the InterQual® criteria, to assist us in administering health benefits. UnitedHealthcare Medical Policies and Medical Benefit Drug Policies are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.
Medical Policies and Medical Benefit Drug Policies are the property of UnitedHealthcare. Unauthorized copying, use, and distribution of this information are strictly prohibited. The InterQual® criteria are proprietary to Change Healthcare and are not published on this website.
When these policies are used to determine medical necessity, clinical guidelines will be applied in the following order:
- State/Federal Guidelines and Contract Requirements
- InterQual® criteria
- UnitedHealthcare Community Plan of Indiana Medical & Drug Policies
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Adzynma (ADAMTS13, Recombinant-Krhn) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses the use of Adzynma (ADAMTS13, recombinant-krhn) for the treatment of congenital thrombotic thrombocytopenic purpura (cTTP). Applicable Procedure Code: J7171.
Alpha1-Proteinase Inhibitors (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 11.01.2024
Effective Date: 11.01.2024 – This policy addresses alpha1-proteinase inhibitors (Aralast NP™, Glassia™, Prolastin®-C, and Zemaira®) for chronic augmentation and maintenance therapy of emphysema due to congenital deficiency of alpha1-proteinase inhibitor (A1-PI)/alpha1-antitrypsin (AAT) deficiency. Applicable Procedure Codes: J0256, J0257.
Benlysta® (Belimumab) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 11.01.2024
Effective Date: 11.01.2024 – This policy addresses the use of Benlysta® (belimumab) injection for intravenous infusion for the treatment of systemic lupus erythematosus (SLE) and active lupus nephritis (LN). Applicable Procedure Code: J0490.
Botulinum Toxins A and B (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 12.01.2024
Effective Date: 04.01.2024 – This policy addresses the use of botulinum toxin types A and B, including Dysport® (abobotulinumtoxinA), Xeomin® (incobotulinumtoxinA), Botox® (onabotulinumtoxinA), and Myobloc® (rimabotulinumtoxinB). Applicable Procedure Codes: J0585, J0586, J0587, J0588, J0589.
Breast Reconstruction (for Indiana Only) – Community Plan Medical Policy
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses breast reconstruction post-mastectomy and for the treatment of Poland syndrome, removal of breast implants, and breast repair and reconstruction not post mastectomy. Applicable Procedure Codes: 11920, 11921, 11922, 11970, 11971, 15271, 15272, 15771, 15772, 15777, 19316, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380, 19396, 19499, L8600, S2066, S2067, S2068, S8950.
Brineura® (Cerliponase Alfa) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 11.01.2024
Effective Date: 11.01.2024 – This policy addresses the use of Brineura® (cerliponase alfa) in pediatric patients with late infantile neuronal ceroid lipofuscinosis (LINCL). Applicable Procedure Code: J0567.
Brow Ptosis and Eyelid Repair (for Indiana Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 12.01.2024 – This policy addresses brow ptosis, browpexy or internal browlift, eyelid surgery for correction of lagophthalmos, lid retraction surgery, and canthoplasty/canthopexy. Applicable Procedure Codes: 15820, 15821, 15822, 15823, 21280, 21282, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67911, 67912, 67914, 67915, 67916, 67917, 67921, 67922, 67923, 67924, 67950, 67961, 67966.
Chelation Therapy for Non-Overload Conditions (for Indiana Only) – Community Plan Medical Policy
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses chelation therapy. Applicable Procedure Codes: J0470, J0600, J0895, J3490, J3520, J8499, M0300, S9355.
Chemotherapy Observation or Inpatient Hospitalization (for Indiana Only) – Community Plan Medical Policy
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses chemotherapy observation or overnight (inpatient) stay.
Complement Inhibitors (PiaSky®, Soliris®, & Ultomiris®) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses the use of PiaSky® (crovalimab-akkz), Soliris® (eculizumab), and Ultomiris® (ravulizumab-cwvz). Applicable Procedure Codes: J1300, J1303, J1307.
Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes (for Indiana Only) – Community Plan Medical Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses insulin delivery and continuous glucose monitoring for diabetes management. Applicable Procedure Codes: 0446T, 0447T, 0448T, 95249, 95250, 95251, A4226, A4238, A4239, A9274, A9276, A9277, A9278, E0784, E0787, E2102, E2103, G0564, G0565, S1030, S1031, S1034, S1035, S1036, S1037.
Core Decompression for Avascular Necrosis (for Indiana Only) – Community Plan Medical Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses core decompression for avascular necrosis. Applicable Procedure Codes: 21299, 23929, 27299, 27599, 27899, S2325.
Crysvita® (Burosumab-Twza) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses the use of Crysvita®(burosumab-twza) for the treatment of X-linked hypophosphatemia (XLH) and Fibroblast Growth Factor 23 (FGF23)-related hypophosphatemia in tumor-induced osteomalacia (TIO). Applicable Procedure Code: J0584.
Deep Brain and Cortical Stimulation (for Indiana Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date 04.01.2024 – This policy addresses deep brain and responsive cortical stimulation. Applicable Procedure Codes: 61850, 61860, 61863, 61864, 61867, 61868, 61885, 61886, 61889, 61891, 64999, L8679, L8680, L8682, L8685, L8686, L8687, L8688.
Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements (for Indiana Only) – Community Plan Medical Policy
Last Published 02.01.2025
Effective Date: 02.01.2025 – This policy addresses durable medical equipment (DME), orthotics, ostomy supplies, medical supplies and repairs/replacements.
Elective Inpatient Services (for Indiana Only) – Community Plan Medical Policy
Last Published 02.01.2025
Effective Date: 02.01.2025 – This policy addresses planned elective inpatient admission for certain surgeries or procedures.
Electric Tumor Treatment Field Therapy (for Indiana Only) – Community Plan Medical Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses the use of devices to generate electric tumor treatment fields (TTF). Applicable Procedure Codes: 77299, A4555, E0766.
Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation (for Indiana Only) – Community Plan Medical Policy
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses functional electrical stimulation (FES) and neuromuscular electrical stimulation (NMES). Applicable Procedure Codes: 0278T, 0720T, 63650, 63655, 63663, 63664, 63685, 64555, 64999, A4556, A4543, A4544, A4557, A4595, E0720, E0721, E0730, E0731, E0743, E0744, E0745, E0764, E0770, E1399, L8679, L8680, L8682, L8685, L8686, L8687, L8688, S8130, S8131.
Electrical Stimulation for Wounds (for Indiana Only) – Community Plan Medical Policy
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses electrical stimulation and electromagnetic therapy for wounds. Applicable Procedure Codes: G0281, G0282.
Electromagnetic Therapy for Wounds (for Indiana Only) – Community Plan Medical Policy
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses electrical stimulation and electromagnetic therapy for wounds. Applicable Procedure Codes: E0769, G0295, G0329.
Enjaymo® (Sutimlimab-Jome) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 12.01.2024
Effective Date: 05.01.2024 – This policy addresses the use of Enjaym® (sutimlimab-jome) for the treatment of cold agglutinin disease (CAD). Applicable Procedure Code: J1302.
Erythropoiesis-Stimulating Agents (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 12.01.2024
Effective Date: 01.01.2024 – This policy addresses the use of erythropoiesis-stimulating agents (ESAs), including Aranesp® (darbepoetin alfa), Epogen® (epoetin alfa), Mircera® (methoxy polyethylene glycol-epoetin beta [MPG-epoetin beta]), Procrit® (epoetin alfa), and Retacrit™ (epoetin alfa). Applicable Procedure Codes: J0881, J0882, J0885, J0887, J0888, Q4081, Q5105, Q5106.
Gamifant® (Emapalumab-Lzsg) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 12.01.2024
Effective Date: 12.01.2024 – This policy addresses the use of Gamifant® (emapalumab-lzsg) for the treatment of primary and secondary hemophagocytic lymphohistiocytosis (HLH). Applicable Procedure Code: J9210.
Gastrointestinal Motility Disorders, Diagnosis and Treatment (for Indiana Only) – Community Plan Medical Policy
Last Published 09.01.2024
Effective Date: 09.01.2024 – This policy addresses gastric electrical stimulation therapy; manometry, sensation, tone, and compliance testing; defecography; and electrogastrography/electroenterography. Applicable Procedure Codes: 0779T, 0868T, 43647, 43648, 43881, 43882, 64590, 64595, 72195, 72196, 72197, 74270, 76496, 91117, 91120, 91122, 91132, 91133, A9286, A9900, A9999, E1399.
Gender Dysphoria Treatment (for Indiana Only) – Community Plan Medical Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses gender dysphoria treatment, including surgical treatment and certain ancillary procedures.
Givlaari® (Givosiran) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 12.01.2024
Effective Date: 05.01.2024 – This policy addresses the use of Givlaari® (givosiran) for the treatment of acute hepatic porphyrias. Applicable Procedure Code: J0223.
Gonadotropin Releasing Hormone Analogs (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 12.01.2024
Effective Date: 11.01.2023 – This policy addresses gonadotropin releasing hormone analog (GnRH analog) drug products. Applicable Procedure Codes: J1950, J1951, J1952, J1954, J3315, J3316, J9155, J9202, J9217, J9225, J9226.
Hearing Aids and Devices Including Wearable, Bone-Anchored, and Semi-Implantable (for Indiana Only) – Community Plan Medical Policy
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses wearable, bone-anchored, and semi-implantable hearing aids and devices.
Hereditary Angioedema (HAE), Treatment and Prophylaxis (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 12.01.2024
Effective Date: 12.01.2024 – This policy addresses the use of C1 esterace inhibitors (human), C1 esterace inhibitors (recombinant), and plasma kallikrein inhibitors (human) for the treatment and prophlaxis of hereditary angioedema (HAE). Applicable Procedure Codes: J0596, J0597, J0598, J1290.
Hospital Services: Observation and Inpatient (for Indiana Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 12.01.2024 – This policy addresses hospital services for observation versus inpatient level of care.
Ilaris® (Canakinumab) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 12.01.2024
Effective Date: 12.01.2024 – This policy addresses the use of Ilaris®. Applicable Procedure Code: J0638.
Immune Globulin (IVIG and SCIG) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses the use of intravenous (IV) and subcutaneous (SC) immune globulin (IG) products. Applicable Procedure Codes: 90283, 90284, J1459, J1551, J1554, J1555, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, J1572, J1575, J1576, J1599.
Immunomodulators for Inflammatory Conditions (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 12.01.2024
Effective Date: 12.01.2024 – This policy addresses immunomodulator agents for inflammatory conditions. Applicable Procedure Codes: C9399, 96372, 96401, J0129, J0717, J1602, J2327, J3245, J3262, J3357, J3358, J3380. J3490, J3590.
Interspinous Fusion and Decompression Devices (for Indiana Only) – Community Plan Medical Policy
Last Published 01.01.2025
Effective Date: 04.01.2024 – This policy addresses interspinous bony fusion devices and decompression systems. Applicable Procedure Codes: 22853, 22854, 22859, 22867, 22868, 22869, 22870, 22899, C1821.
Intracanalicular and Intravitreal Corticosteroid Implants (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses the use of specialty pharmacy medications administered by the intravitreal route for certain ophthalmologic conditions. Applicable Procedure Codes: J1096, J7311, J7312, J7313, J7314.
Intrauterine Fetal Surgery (for Indiana Only) – Community Plan Medical Policy
Last Published 09.01.2024
Effective Date: 09.01.2024 – This policy addresses intrauterine fetal surgery (IUFS) and fetoscopic endoluminal tracheal occlusion (FETO) . Applicable Procedure Codes: 59072, 59074, 59076, 59897, S2400, S2401, S2402, S2403, S2404, S2405, S2409, S2411.
Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses the use of intravenous enzyme replacement drug products for the treatment of Gaucher disease, including Cerezyme® (imiglucerase), Elelyso® (taliglucerase), and VPRIV® (velaglucerase). Applicable Procedure Codes: J1786, J3060, J3385.
Intravenous Iron Replacement Therapy (Feraheme®, Injectafer®, & Monoferric®) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 12.01.2024
Effective Date: 02.01.2024 – This policy addresses the use of Feraheme® (ferumoxytol), Injectafer® (ferric carboxymaltose), and Monoferric® (ferric derisomaltose) for intravenous iron replacement therapy. Applicable Procedure Codes: J1437, J1439, Q0138, Q0139.
Korsuva® (Difelikefalin) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses the use of Korsuva (difelikefalin) for the treatment of moderate-to-severe pruritus associated with chronic kidney disease in adults undergoing hemodialysis. Applicable Procedure Code: J0879.
Light and Laser Therapy (for Indiana Only) – Community Plan Medical Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses light and laser therapy, including light phototherapy, photodynamic therapy, intense pulsed light, pulsed dye laser, and laser hair removal. Applicable Procedure Codes: 17106, 17107, 17108, 17999, 96999.
Long-Acting Injectable Antiretroviral Agents for HIV (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses the use of Apretude (cabotegravir) to reduce the risk of sexually acquired HIV-1 infection and Cabenuva (cabotegravir/rilpivirine) for the treatment of a human immunodeficiency virus type-1 (HIV-1) in patients who are virologically suppressed. Applicable Procedure Codes: J0739, J0741, J1961.
Maximum Dosage and Frequency (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses the maximum dosage per administration and dosing frequency for certain medications administered by a medical professional.
Mechanical Stretching Devices (for Indiana Only) – Community Plan Medical Policy
Last Published 02.01.2025
Effective Date: 02.01.2025 – This policy addresses the use of low-load prolonged-duration stretch devices, static progressive (SP) stretch splint devices, and patient actuated serial stretch (PASS) devices. Applicable Procedure Codes: E1399, E1800, E1801, E1802, E1803, E1804, E1805, E1806, E1807, E1808, E1810, E1811, E1812, E1813, E1814, E1815, E1816, E1818, E1822, E1823, E1825, E1826, E1827, E1828, E1829, E1830, E1831, E1840, E1841.
Medical Therapies for Enzyme Deficiencies (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses drug products used as medical therapies for enzyme deficiency. Applicable Procedure Codes: J0180, J0218, J0219, J0217, J0221, J1203, J1322, J1458, J1743, J1931, J2508, J2840, J3397, J3490, J3590.
Minimally Invasive Spine Surgery Procedures (for Indiana Only) – Community Plan Medical Policy
Last Published 02.01.2025
Effective Date: 08.01.2024 – This policy addresses minimally invasive spine surgery procedures. Applicable Procedure Codes: 0200T, 0201T, 0275T, 22586, 22630, 22899, 62287, 62380, G0276.
Neonatal Fc Receptor Blockers (Rystiggo®, Vyvgart®, & Vyvgart® Hytrulo) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses the use of Rystiggo®, Vyvgart®, & Vyvgart® Hytrulo for the treatment of myasthenia gravis. Applicable Procedure Codes: J9332, J3490, J3590.
Neurophysiologic Testing and Monitoring (for Indiana Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 04.01.2024 – This policy addresses nerve conduction studies and other neurophysiological testing.
Nplate® (Romiplostim) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses the use of Nplate® (romiplostim) for the treatment of chronic immune thrombocytopenic purpura (ITP). Applicable Procedure Code: J2802.
Obstructive and Central Sleep Apnea Treatment (for Indiana Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 12.01.2024 – This policy addresses nonsurgical and surgical treatment of obstructive sleep apnea (OSA). Applicable Procedure Codes: 21142, 21199, 21206, 21685, 33276, 33277, 33278, 33279, 33280, 33281, 33287, 33288, 41512, 41530, 41599, 42140, 42145, 42299, 64570, 64582, 64583, 64584, 93150, 93151, 93513, EE0485, E0486, E0492, E0493, E0530, E1399, K1027, L8679, L8680, L8686, S2080, S2900.
Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache) (for Indiana Only) – Community Plan Medical Policy
Last Published 02.01.2025
Effective Date: 10.01.2024 – This policy addresses occipital neuralgia and headache treatments, including occipital nerve blocks and occipital nerve ablation. Applicable Procedure Codes: 63185, 63190, 64405, 64553, 64555, 64568, 64570, 64575, 64590, 64596, 64597, 64598, 64633, 64634, 64722, 64744, 64771, 64999, A4540, L8679, L8680, L8685.
Off-Label/Unproven Specialty Drug Treatment (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses off-label and unproven indications of FDA-approved specialty drugs.
Omnibus Codes (for Indiana Only) – Community Plan Medical Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses multiple services/procedures.
Oncology Medication Clinical Coverage (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses parameters for coverage of injectable oncology medications.
Ophthalmologic Complement Inhibitors (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 12.01.2024
Effective Date: 12.01.2024 – This policy addresses the use of Izervay™ (avacincaptad pegol) and Syfovre™ (pegcetacoplan injection) for the treatment of geographic atrophy (GA) secondary to age-related macular degeneration (AMD). Applicable Procedure Codes: J2781, J2782.
Ophthalmologic Policy: Vascular Endothelial Growth Factor (VEGF) Inhibitors (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses the use of vascular endothelial growth factor (VEGF) inhibitors. Applicable Procedure Codes: J0177, J0178, J0179, J2777, J2778, J2779, J9035, Q5124, Q5128.
Parsabiv® (Etelcalcetide) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 12.01.2024
Effective Date: 04.01.2024 – This policy addresses the use of Parsabiv® (etelcalcetide) for the treatment of secondary hyperparathyroidism with chronic kidney disease. Applicable Procedure Code: J0606.
Prostate Surgeries and Interventions (for Indiana Only) – Community Plan Medical Policy
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses prostate surgeries and interventions, including transurethral ablation, cryoablation, surgical prostatectomy, prostatic urethral lift (PUL), high-energy water vapor thermotherapy, and transperineal placement of biodegradable material. Applicable Procedure Codes: 0421T, 0582T, 0619T, 0655T, 0714T, 0738T, 0739T, 0867T, 37243, 52441, 52442, 53850, 53852, 53854, 53855, 55873, 55874.
Qalsody® (Tofersen) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 09.01.2024
Effective Date: 09.01.2024 – This policy addresses the use of Qalsody® (tofersen) for the treatment of amyotrophic lateral sclerosis (ALS). Applicable Procedure Code: J1304.
Radicava® (Edaravone) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses the use of Radicava® (edaravone) for the treatment of amyotrophic lateral sclerosis (ALS). Applicable Procedure Code: J1301.
Rebyota® (Fecal Microbiota, Live-Jslm) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses the use of Rebyota® (fecal microbiota, live-jslm) for prevention of the recurrence of clostridioides difficile infection (CDI). Applicable Procedure Code: J1440.
Repository Corticotropin Injections (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 12.01.2024
Effective Date: 04.01.2024 – This policy addresses the use of repository corticotropin injections (Acthar® Gel and Purified Cortophin Gel™). Applicable Procedure Codes: J0801, J0802.
Review at Launch for New to Market Medications (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 02.14.2025
Effective Date: 12.01.2024 – This policy addresses review of certain new to market medications that are healthcare provider administered. Applicable Procedure Codes: C9399, J3490, J3590.
Rhinoplasty and Other Nasal Procedures (for Indiana Only) – Community Plan Medical Policy
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses rhinoplasty and other nasal surgeries. Applicable Procedure Codes: 30117, 30120, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 30468, 30469, 30999, 31237, 31242, 31243, 64999, L8699.
Rituximab (Riabni®, Rituxan®, Ruxience®, & Truxima®) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses the use of Riabni® (rituximab-arrx), Rituxan® (rituximab), Ruxience® (rituximab-pvvr), and Truxima® (rituximab-abbs). Applicable Procedure Codes: J3590, J9311, J9312, J999, Q5115, Q5119, Q5123.
Rivfloza® (Nedosiran) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 12.01.2024
Effective Date: 12.01.2024 – This policy addresses the use of Rivfloza® (Nedosiran) for the treatment of primary hyperoxaluria type 1 (PH1). Applicable Procedures Code: J3490.
RNA-Targeted Therapies (Amvuttra® and Onpattro®) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses the use of Onpattro® (patisiran) and Amvuttra® (vutrisiran) for the treatment of polyneuropathy of hereditary transthyretin-mediated (hATTR) amyloidosis. Applicable Procedure Codes: C9399, J0222, J3490, J3590.
Ryplazim® (Plasminogen, Human-Tvmh) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 12.01.2024
Effective Date: 04.01.2024 – This policy addresses the use of Ryplazim® (plasminogen, human-tvmh) for the treatment of plasminogen deficiency type 1 (hypoplasminogenemia). Applicable Procedure Code: J2998.
Saphnelo® (Anifrolumab-Fnia) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses the use of Saphnelo® (Anifrolumab-Fnia) for the treatment of moderate to severe systemic lupus erythematosus (SLE). Applicable Procedure Code: J0491.
Self-Administered Medications (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses medications that are determined to be self-administered and excluded from medical coverage.
Sodium Hyaluronate (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses the use of sodium hyaluronate products. Applicable Procedure Codes: 20605, 20606, 20610, 20611, J3490, J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332.
Subcutaneous Implantable Naltrexone Pellets (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses the use of compounded implantable drug pellets. Applicable Procedure Codes: 11981, 11982, 11983, J3490, J7999.
Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins (for Indiana Only) – Community Plan Medical Policy
Last Published 11.01.2024
Effective Date: 11.01.2024 – This policy addresses varicose vein ablative and stripping procedures, ligation procedures, ambulatory phlebectomy, sclerotherapy, and endovascular embolization. Applicable Procedure Codes: 0744T, 36465, 36466, 36468, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37500, 37700, 37718, 37722, 37735, 37765, 37766, 37780, 37785, 37799.
Surgical Treatment of Lymphedema (for Indiana Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 02.01.2024 – This policy addresses surgical procedures for the treatment or prevention of lymphedema. Applicable Procedure Codes: 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 15876, 15877, 15878, 15879, 38999, 49906.
Tepezza® (Teprotumumab-Trbw) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses the use of Tepezza® (teprotumumab-trbw) for the treatment of thyroid eye disease. Applicable Procedure Code: J3241.
Testosterone Replacement or Supplementation Therapy (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses the use of injectable testosterone and testosterone pellets for replacement therapy in conditions associated with a deficiency or absence of endogenous testosterone. Applicable Procedure Codes: 11980, J1071, J3121, J3145, S0189.
Transcatheter Heart Valve Procedures (for Indiana Only) – Community Plan Medical Policy
Last Published 12.01.2024
Effective Date: 05.01.2024 – This policy addresses transcatheter heart valve (aortic, mitral, pulmonary) procedures. Applicable Procedure Codes: 0345T, 0483T, 0484T, 0543T, 0544T, 0545T, 0569T, 0570T, 0646T, 0805T, 0806T, 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369, 33370, 33418, 33419, 33477, 33999, 93799.
Treatment of Temporomandibular Joint Disorders (for Indiana Only) – Community Plan Medical Policy
Last Published 11.01.2024
Effective Date: 03.01.2024 – This policy addresses treatment of temporomandibular joint (TMJ) disorders. Applicable Procedure Codes: 20552, 20553, 20605, 20606, 21010, 21050, 21060, 21070, 21085, 21089, 21110, 21240, 21242, 21243, 21247, 21299, 21499, 29800, 29804, 90901, 97039, 97139, E0746, E1399, E1700, E1701, E1702.
Trogarzo® (Ibalizumab-Uiyk) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses the use of Trogarzo® (ibalizumab-uiyk) for the treatment of multi-drug resistant human immunodeficiency virus (HIV). Applicable Procedure Code: J1746.
Umbilical Cord Blood Harvesting and Storage for Future Use (for Indiana Only) – Community Plan Medical Policy
Last Published 09.01.2024
Effective Date: 09.01.2024 – This policy addresses collection and storage of umbilical cord blood. Applicable Procedure Codes: 38205, 38206, 38207, 88240, S2140.
Uplizna® (Inebilizumab-Cdon) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses Uplizna® (inebilizumab-cdon) for the treatment of neuromyelitis optica spectrum disorder (NMOSD). Applicable Procedures Code: J1823.
Veopoz™ (Pozelimab-Bbfg) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses the use of Veopoz™ (pozelimab-bbfg) for the treatment of CD55-deficient protein-losing enteropathy (PLE) (i.e., CHAPLE disease). Applicable Procedure Codes: C9399, J3490, and J3590.
White Blood Cell Colony Stimulating Factors (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses the use of white blood cell colony stimulating factors (CSFs), including the drug products Fulphila, Granix, Leukine, Neulasta, Neupogen, Nivestym, Nyvepria, Releuko, Udenyca, Zarxio, and Ziextenzo. Applicable Procedure Codes: J1442, J1447, J1449, J2506, J2820, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125, Q5127, Q5130.
Xiaflex® (Collagenase Clostridium Histolyticum) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses the use of Xiaflex® (collagenase clostridium histolyticum) for the treatment of Dupuytren’s contracture and Peyronie’s disease. Applicable Procedure Codes: 20527, 26341, J0775.
Xolair® (Omalizumab) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses the use of Xolair® (omalizumab). Applicable Procedure Code: J2357.
Zulresso® (Brexanolone) (for Indiana Only) – Community Plan Medical Benefit Drug Policy
Last Published 11.01.2024
Effective Date: 11.01.2024 – This policy addresses the use of Zulresso® (brexanolone) for the treatment of postpartum depression (PPD) in adults. Applicable Procedure Code: J1632.