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 Prior Authorization lookup tool
The Ohio Medicaid state specific clinical criteria information is alphabetized below. Not all drugs requiring authorization have Ohio
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
OHIO SPECIFIC POLICIES
| Clinical Criteria | Associated Medications (as applicable) | Document Number | Coding |
|---|---|---|---|
| Agents for Hemophilia B | Factor IX (Human) [Alphanine SD, Mononine. Factor IX Complex (Human) [(Factors II, IX, X)] [Profilnine SD]. Factor IX (Recombinant) [Benefix, Ixinity, Rixubis]. Factor IX (Recombinant [Albumin Fusion Protein]) [Idelvion]. Factor IX (Recombinant [Fc Fusion Protein]) [Alprolix]. Factor IX (Recombinant [Glycopegylated]) [Rebinyn]. | OH UPDL Criteria | J7193, J7194, J7195, J7200 J7201, J7202, J7203, J7213 |
| Aristada Initio (aripiprazole lauroxil) | Aristada Initio (aripiprazole lauroxil) | OH UPDL Criteria | J1943 |
| Cardiovascular Agents: Lipotropics | Praluent (alirocumab), Repatha (evolocumab) | OH UPDL Criteria | C9399, J3490, J3590 |
| Central Nervous System (CNS) Agents: Multiple Sclerosis | Kesimpta (Ofatumumab) | OH UPDL Criteria | J3490, J3590, C9399 |
| Colony Stimulating Factors | Elfapegrastim agents (Rolvedon). Elbemalenograstim agents (Ryzneuta). Filgrastim agents (Neupogen, Nivestym, Nypozi, Releuko, Zarxio, Granix). Pegfilgrastim agents (Neulasta/Neulasta Onpro, Fulphila, Fylnetra, Nyvepria, Stimufend, Udenyca/Udenyca Onbody, Ziextenzo). Sargramostim agents (Leukine, Prokine) | OH UPDL Criteria | 96377, C9173, J3590, J1442, J1447, J1449, J2506, J2820, J9361, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125, Q5127, Q5130 |
| Dihydroergotamine (DHE) Injection | Dihydroergotamine | OH UPDL Criteria | J1110 |
| Duchenne Muscular Dystrophy Agents | Amondys 45 (casimersen) Exondys 51 (eteplirsen) Vyondys 53 (golodirsen) | MCD-OH 0189, MCD-OH 0044, MCD-OH 0152 | J1426, J1428, J1429 |
| Growth Hormone | Somatropin: Genotropin, Humatrope, Norditropin, Nutropin AQ, Omnitrope, Saizen, Serostim, Zomacton, Zorbtive; Somapacitan-beco: Sogroya; Somatrogon-ghla: NGENLA. Lonapegsomatropin-tcgd: Skytrofa | OH UPDL Criteria | J2940, J2941, S9558, J3490, J3590, C9399 |
| Immunomodulator Agents | Adbry (tralokinumab), Entyvio (vedolizumab), Stelara (ustekinumab), Wezlana (ustekinumab-auub), Selarsdi(ustekinumab-aekn), Adalimumab agents (Humira, Adalimumab unbranded, Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Simlandi, Yuflyma, Yusimry), Certolizumab pegol (Cimzia), Etanercept agents (Enbrel, Erelzi, Eticovo), Golimumab (Simponi, Simponi Aria), Infliximab agents (Remicade, Infliximab unbranded, Avsola, Inflectra, Ixifi, Renflexis, Zymfentra), Actemra (tocilizumab), Tofidence (tocilizumab-bavi), Tyenne (tocilizumab-aazg), Kevzara (sarilumab), Ilumya (tildrakizumab-asmn), Omvoh (mirikizumab-mrkz), Skyrizi (risankizumab-rzaa), Tremfya (guselkumab) | OH UPDL Criteria | J3490, J3380,J3357,J3262,Q5133, J3358, J3590,J0139, J0717, J1438, J1602, J1745, J1748, Q5103, Q5104, Q5109, Q5121, Q5140, Q5141, Q5142, Q5143, Q5144, Q5145, S9359, C9399, Q5137, Q5138, Q9998, Q0249, J1628, J3245, J2327, J2267 |
| Infectious Disease Agents: Antivirals – HIV | Cabenuva, Fuzeon(enfuvirtide) | OH UPDL Criteria | J0741, J1324 |
| Monoclonal Antibody for RSV | Synagis (palivizumab) | MCD-OH 0007 | 90378, S9562 |
| Respiratory Agents: Monoclonal Antibodies-Anti-IL/Anti-IgE | Dupixent(dupilumab), Xolair(omalizumab), Tezspire (tezepelumab-EKKO), Fasenra (benralizumab), Nucala (mepolizumab), Cinqair (reslizumba) | OH UPDL Criteria | J0517, J2182, J2786, C9399, J3590, J2357, J2356 |
(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.