J2267, Injection, mirikizumab-mrkz, 1 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Therapy must be proven effective for the relevant diagnosis or procedure and this should be documented in the medical record.
- For drug therapy, proposed dose, frequency, and duration must be consistent with recommendations from at least one authoritative source.
- Supportive references may include FDA-approved labeling, MCG care guidelines, DrugDex (IIa level or higher), NCCN Guidelines/Compendia (IIb level or higher), peer‑reviewed literature, and generally accepted standards of medical care.
- Providers and members must consult and document the member's benefit plan, summary plan description, or contract to determine applicable coverage, exclusions, and limitations.
Key Coverage Criteria
- Indication: Ulcerative colitis - diagnosis of moderately to severely active UC with three IV induction doses per FDA-labeled UC dosing, not in combination with another systemic targeted immunomodulator, authorization for 3 induction doses.
- Covered when hospital outpatient facility infusion services for specialty medications and IVIG/SCIG therapy are considered medically necessary and the member meets the specific clinical criteria described in the policy.
- Coverage of an FDA‑approved drug when prescribed for a use recognized as safe and effective in one or more standard medical reference compendia adopted by the U.S. Department of Health and Human Services.
- Coverage of an FDA‑approved drug for an off‑label use when medical literature demonstrates safety and efficacy confirmed in two articles from major peer‑reviewed professional medical journals presenting data supporting the proposed off‑label use.
- Intravenous administration of mirikizumab-mrkz (Omvoh) when used for FDA‑labeled indications.
- Adults (≥18 years) with moderately to severely active ulcerative colitis who have had inadequate response, loss of response, or intolerance to corticosteroids, 6‑mercaptopurine, azathioprine, biologic therapy (TNF blocker, vedolizumab), or tofacitinib, and who have no active infection.
10 Active Policies
UHC-POL-omvoh, Omvoh (Mirikizumab-Mrkz)
UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care
RX501.168, Mirikizumab-mrkz
BCBSIL-RX501.168, Mirikizumab-mrkz
BCBSMT-RX501.168, Mirikizumab-mrkz
Related Codes
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