Welcome to the Clinical Criteria Page
This page provides the clinical criteria documents for all injectable, infused, or implanted
prescription drugs and therapies covered under the medical benefit. The effective dates for using these
documents for clinical reviews are communicated through the Provider notification process.
To determine if a code requires authorization, use the Precertification
lookup tool
The Indiana Medicaid state-specific clinical criteria information is alphabetized below. Not all drugs
requiring authorization have Indiana Medicaid State specific criteria. If a code requires authorization
and the clinical criteria document is not found in the list below, please utilize the following link for
additional criteria.Clinical
Criteria
INDIANA SPECIFIC POLICIES
| Clinical Criteria | Associated Medications (as applicable) | Document Number | Coding |
|---|---|---|---|
| Amyloid Beta-Directed Antibodies | Aduhelm (aducanumab-AVWA), Leqembi (lecanemab), Kisnula (donanemab-AZBT) | IHCP criteria | J0172, J0174, J0175 |
| Multiple Sclerosis Agents | Tysabri (natalizumab), Avonex (interferon beta-1a), Betaseron (interferon beta-1b), Briumvi (ublituximab-XIIY), Copaxone (glatopa, glatiramer), Extavia (interferon beta-1b), Kesimpta (ofatumumab), Lemtrada (alemtuzumab), Ocrevus (ocrelizumab), Ocrevus Zunovo (ocrelizumab & hyaluronidase-ocsq), Plegridy (interferon beta-1a), Rebif (interferon beta-1a) | IHCP criteria | C9399, J0202, J1595, J1826, J1830, J2323, J2329, J2350, J3490, J3590, Q3027, Q3028 |
| Thrombopoietin Receptor Agonists | Nplate (romiplostim) | IHCP criteria | J2796 |
| Phenylketonuria Agents | Palynziq (pegvaliase-pqpz) | IHCP criteria | J3590, C9399 |
| Ebglyss | Ebglyss (lebrikizumab-lbkz) | IHCP criteria | J3590, C9399 |
| Leukocyte Stimulants | Short-Acting (Neupogen (filgrastim), Granix (tbo-filgrastim), Leukine (sargramostim), Nivestym (filgrastim-AAFI), Releuko(filgrastim-AYOW), Zarxio (filgrastim-SNDZ)); Long Acting (Fylnetra (pegfilgrastim-PBBK), Nyvepria (pegfilgrastim-APGF), Fulphila (pegfilgrastim-JMDB), Neulasta (pegfilgrastim), Neulasta Onpro (pegfilgrastim), Rolvedon (eflapegrastim-XNST), Stimufend (pegfilgrastim-FPGK), Udenyca (pegfilgrastim-CBQV), Udenyca Onbody (pegfilgrastim-CBQV), Ziextenzo (pegfilgrastim-BMEZ)) | IHCP criteria | J1442, J1447, J1449, J2506, J2820, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125, Q5127, Q5130 |
| Targeted Immunomodulators | Actemra (tocilizumab), Tyenne (tocilizumab-AAZG), Tofidence (tocilizumab-BAVI); adalimumab-FKJP (generic Hulio), Hadlima (adalimumab-BWWD), Humira (adalimumab); Adbry (tralokinumab); Enbrel (entanercept); Remicade (infliximab), Zymfentra (infliximab-DYYB); Kineret (anakinra); Orencia (abatacept); Simponi (golimumab); Taltz (ixekizumab); Avsola (infliximab-AXXQ); Cimzia (certolizumab); Cosentyx (secukinumab); Entyvio (vedolizumab); Kevzara (sarilumab); Siliq (brodalumab); Abrilada (adalimumab-AFZB), adalimumab-AACF (generic Idacio), adalimumab-ADAZ (generic Hyrimoz), adalimumab-ADBM (generic Cyltezo), adalimumab-RYVK (generic Simlandi), Amjevita (adalimumab-ATTO), Cyltezo (adalimumab-ADBM), Hulio (adalimumab-FKJP), Hyrimoz (adalimumab-ADAZ), Idacio (adalimumab-AACF), Yuflyma (adalimumab-AATY), Yusimry (adalimumab-AQVH), Simlandi (adalimumab-RYVK); Arcalyst (rilonacept); Bimzelx (bimekizumab-BKZX); Ilaris (canakinumab); Ilumya (tildrakizumab-ASMN); Inflectra (infliximab-DYYB), Renflexis (infliximab-ABDA); Omvoh (mirikizumab-MRKZ); Skyrizi (risankizumab-RZAA); Spevigo (spesolimab-SBZO); Stelara (ustekinumab); Tremfya (guselkumab) | IHCP criteria | J0129, J0135, J0638, J0717, J1438, J1602, J1628, J1745, J1747, J1748, J2267, J2327, J2793, J3245, J3247, J3262, J3357, J3358, J3380, J3490, J3590, Q5103, Q5104, Q5121, Q5131, Q5132, Q5133, Q5135, C9399 |
| Hematinic Agents | Aranesp (darbepoetin alfa); Epogen (epoetin alfa), Mircera (methoxy polyethylene glycol-epoetin beta), Procrit (epoetin alfa), Reblozyl (lusapatercept), Retacrit (epoetin alfa-epbx) | IHCP criteria | J0881, J0882, J0885, J0887, J0888, J0896, Q4081, Q5105, Q5106 |
| Growth Hormone | Genotropin, Humatrope, Norditropin, Nutropin AQ, Omnitrope, Saizen, Serostim, Zomacton (somatropin); Sogroya (somapacitan-beco); Skytrofa (lonapegsomatropin-TCGD); Increlex (mecasermin); Ngenla (somatrogon-GHLA); Voxzogo (vosoritide) | IHCP criteria | J2170, J2941, J3490, J3590, C9399 |
| Human Chorionic Gonadotropic (HCG) | Human Chorionic Gonadotropin (HCG) | IHCP criteria | J0725 |
| Opioid Use Disorder Treatments | Brixadi (buprenorphine), Sublocade (buprenorphine) | IHCP criteria | J0577, J0578, Q9991, Q9992 |
| Somatostatin Analog | Sandostatin (octreotide), Sandostatin LAR Depot (octreotide), Signifor (pasireotide diaspartate), Signifor LAR (pasireotide pamoate), Somatuline Depot (lanreotide), Lanreotide | IHCP criteria | J1930, J1932,J2353, J2354, J2502, J3490 |
| PCSK9 Inhibitors and Select Lipotropics | Evkeeza (evinacumab-DGNB), Leqvio (inclisiran), Praluent (alirocumab), Repatha (evolocumab) | IHCP criteria | J1305, J1306, J3490, J3590, C9399 |
| Pulmonary Antihypertensives | Tyvaso (treprostinil), Ventavis (iloprost), Winrevair (sotatercept-csrk) | IHCP criteria | J3590, J7686, Q4074, C9399 |
| Respiratory and Allergy Biologics | Cinqair (reslizumab), Dupixent (dupilumab), Fasenra (benralizumab), Nucala (mepolizumab), Tezpire (tezepelumab-EKKO), Xolair (omalizumab) | IHCP criteria | J0517, J2182, J2356, J2357, J2786, J3590, C9399 |
| Testosterones | Aveed (testosterone undecanoate), Delatestryl (testosterone enanthate), Depo-Testosterone (testosterone cypionate), Testopel (testosterone implant pellet), Xyosted (testosterone enanthate) | IHCP criteria | J1071, J3121, J3145, J3490 |
| Pompe Disease Agents | Pombiliti (cipaglucosidase alfa), Nexviazyme (avalglucosidase alfa-ngpt), Lumizyme (alglucosidase alfa) | IHCP criteria | J1203, J0219, J0221 |
| Intravesical Immunotherapy Agents | Adstiladrin (nadofaragene firadenovec-vncg), Anktiva (nogapendekin alfa inbakicept) | IHCP criteria | J9029, C9169 |
| Antimigraine | Vyepti (eptinezumab-JJMR) | IHCP criteria | J3032 |
| Bone Formation Stimulating Agents | Evenity (romosozumab), Forteo (teriparatide), Tymlos (abaloparatide) | IHCP criteria | J3110, J3111, J3490, C9399 |
| Bone Resorption Inhibitors | Prolia (denosumab), Xgeva (denosumab) | IHCP criteria | J0897 |
| Complement Inhibitor Agents | Soliris (eculizumab), Ultomiris (ravulizumab-cwvz), Piasky (crovalimab-akkz), Empaveli (pegcetacoplan) | IHCP criteria | J1300, J1303, J3490, J3590, C9399 |
(Note: in the case of a clinical criteria document being listed on both sites, please utilize those
listed directly above.)
If you have questions or feedback, please contact druglist@carelon.com.