Summary
UnitedHealthcare Community Plan of Indiana revised its Medicaid Erythropoiesis-Stimulating Agents medical benefit drug policy, effective 2026-12-01. Coverage criteria now use "ESAs" as the umbrella term for all listed agents, treat each hematocrit value as either pretreatment (first 4-6 weeks) or on-treatment monitoring, and use a hemoglobin-to-hematocrit conversion factor of 3 when only hemoglobin is measured. The policy also removes language stating it does not apply to Indiana.
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What to do
Action · 3 steps
01By 2026-12-01: Billing team should update prior authorization checklists for Indiana Medicaid members receiving Aranesp, Epogen, Procrit, Retacrit, or Mircera, aligning initial and continuation requests with the revised CKD, cancer chemotherapy, and other indication criteria (including 12-month initial and reauthorization limits).
02Providers and front desk staff should be told to document pretreatment hematocrit and on-treatment hematocrit values, and to record hemoglobin-derived hematocrit estimates using the factor of 3 where only hemoglobin was measured, so requests and supporting records match the policy.
03Billing team should review charge entry and claim edits for these agents so claims carry the supporting documentation the policy requires; claims submitted without the required criteria documentation will be subject to denial under the payer's rules.
Original notice
Erythropoiesis-Stimulating Agents
uhcprovider.com · Always check the source before changing claims.