C9090 Plasminogen, human-tvmh 1 mgInjection, plasminogen, human-tvmh, 1 mg
8 of 8 payer prior-auth lists that name C9090 require prior authorization or set conditions: Molina Healthcare of Ohio, Molina Healthcare of Texas, UnitedHealthcare Community Plan.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Molina Healthcare of Ohio | Medicaid and MyCare Ohio (MMP) Medicaid | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of Ohio | Medicare and MyCare Ohio (MMP) Medicare | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of Ohio | Exchange | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of Texas | Exchange | TX | prior auth required | Jul 1, 2022 | Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026 | |
| UnitedHealthcare Community Plan | Minnesota Metro Medicaid | MN | prior auth required | Oct 1, 2024 | Prior authorization requirements for Minnesota Medicaid Effective October 1, 2024 | |
| UnitedHealthcare Community Plan | TennCare | TN | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Tennessee Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of Florida | FL | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHeathcare Community Plan of Florida Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of New York | NY | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of New York Effective October 1, 2026 |
C9090 appears in 2 coverage policies from Aetna, Wellmark Blue Cross Blue Shield.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Injectable Medications (0020) | listed, no stance (range C8957-C9235) | Mar 5, 2026 | payer document |
| Wellmark Blue Cross Blue Shield | Ryplazim (plasminogen, human-tvmh) (05.04.44) | listed, no stance | Oct 1, 2025 | payer document |
From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.