ModifiedColorado Rocky Mountain Health PlansPolicy 2026D0030AQ

Oncology Medication Clinical Coverage – Commercial Medical Benefit Drug Policyopen_in_new

Defines coverage parameters for injectable oncology medications (including therapeutic radiopharmaceuticals) under the medical benefit based primarily on NCCN Drugs & Biologics Compendium categories and FDA labeling; lists UnitedHealthcare preferred and non-preferred oncology products and applicable HCPCS/J-codes and billing codes. Excludes CAR-T/TIL products and points to separate policies for CSFs and ESAs.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOncology Medication Clinical Coverage – Commercial Medical Benefit Drug Policyopen_in_new

Policy CodePolicy 2026D0030AQ

Change TypePreferred/non-preferred list updatedcodes addedcoverage basis clarified

Effective DateApr 1, 2026

Next Review Date

Key ActionMembers new to therapy must use UnitedHealthcare preferred oncology products; coverage for non-preferred products requires documentation of prior intolerance/contraindication to a preferred product and physician attestation that the issue would not occur with the non-preferred product.

SourceLink

POLICY UPDATE CHANGES

Revised list of UnitedHealthcare preferred and non-preferred oncology products; added J9174 (Beizray), J9045 (Carboplatin), and J9275 (cosibelimab) to Applicable Codes.

Added language that coverage determinations shall be based upon FDA labeling when no NCCN Compendium entry exists.

Clarified any U.S. FDA-approved product not listed by name will be considered non-preferred until review by UnitedHealthcare P&T committee.

Updated CMS and References sections to reflect current information and archived prior policy version 2026D0030AP.

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Coverage Summary & Basis

This policy aligns coverage of injectable oncology medications (including therapeutic radiopharmaceuticals) primarily with the NCCN Drugs & Biologics Compendium, recognizing indications with NCCN Categories of Evidence and Consensus 1, 2A, or 2B as proven and medically necessary; treatments with NCCN Category 3 are considered unproven and not medically necessary.

When there is no entry in the NCCN Compendium for a specific indication, coverage determinations are based on FDA labeling. The policy excludes CAR-T and TIL products from its coverage criteria and notes that White Blood Cell Colony Stimulating Factors and Erythropoiesis-Stimulating Agents are addressed under separate policies.

For pediatric patients, the policy provides automatic coverage of all chemotherapy agents for oncology indications for individuals under the age of 19 years.

General Medical Necessity / Coverage Basis

UnitedHealthcare recognizes as proven and medically necessary when listed in the NCCN Compendium with evidence category 1, 2A, or 2B; Category 3 is unproven and not medically necessary. When no NCCN entry exists, coverage is based on FDA labeling.

ALL of the following

Drug or therapeutic radiopharmaceutical is listed in the NCCN Drugs & Biologics Compendium with Category of Evidence and Consensus of 1, 2A, or 2B
If no NCCN Compendium entry exists for the indication, coverage determination is based on FDA labeling
For pediatric patients (<19 years), all chemotherapy agents are covered for oncology indications

NCCN Category 3

Consequences when NCCN category is 3:

ALL of the following

Treatments with NCCN Category 3 are considered unproven and not medically necessary

Preferred vs Non-Preferred Products & Provider Requirements

Preferred Product / Non-Preferred Product Criteria

ALL of the following

Member has a documented history of intolerance or contraindication to one of Colorado Rocky Mountain Health Plans' preferred oncology products.
The prescribing physician attests that, in their clinical judgment, the same intolerance, contraindication, or adverse event would not be expected to occur with the requested non-preferred product.

Prior Authorization

Prior Authorization / Product Preference

Prior authorization is required for members new to therapy to ensure use of the payer's preferred oncology products. Requests for a non-preferred oncology product must document meeting the Preferred Product Criteria (history of intolerance/contraindication and physician attestation).

Applicable Codes (HCPCS / J-codes / Q-codes)

Therapeutic radiopharmaceutical HCPCS (reference)HCPCS

A9513	Lutetium lu 177, dotatate, therapeutic, 1 millicurie
A9590	Iodine i-131, iobenguane, 1 millicurie
A9606	Radium Ra-223 dichloride, therapeutic, per microcurie
A9607	Lutetium Lu 177 vipivotide tetraxetan, therapeutic, 1 millicurie
A9699	Radiopharmaceutical, therapeutic, not otherwise classified

Injectable oncology J-codes (reference)HCPCS

J0640	Injection, leucovorin calcium, 50 mg
J0641	Injection, levoleucovorin, not otherwise specified, 0.5 mg
J0642	Injection, levoleucovorin (khapzory), 0.5 mg
J0897	Injection, denosumab, 1 mg
J1323	Injection, elranatamab-bcmm, 1 mg
J1950	Injection, leuprolide acetate (for depot suspension), 3.75 mg
J1954	Injection, leuprolide acetate for depot suspension (lutrate depot), 7.5 mg
J3263	Injection, toripalimab-tpzi, 1 mg
J9022	Injection, atezolizumab, 10 mg
J9024	Injection, atezolizumab, 5 mg and hyaluronidase-tqjs

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Biosimilar Q-codes (reference)HCPCS

Q5107	Injection, bevacizumab-awwb, biosimilar (mvasi), 10 mg
Q5112	Injection, trastuzumab-dttb, biosimilar (ontruzant), 10 mg
Q5113	Injection, trastuzumab-pkrb, biosimilar (herzuma), 10 mg
Q5114	Injection, trastuzumab-dkst, biosimilar (ogivri), 10 mg
Q5115	Injection, rituximab-abbs, biosimilar (truxima), 10 mg
Q5116	Injection, trastuzumab-qyyp, biosimilar (trazimera), 10 mg
Q5117	Injection, trastuzumab-anns, biosimilar (kanjinti), 10 mg
Q5118	Injection, bevacizumab-bvzr, biosimilar (zirabev), 10 mg
Q5119	Injection, rituximab-pvvr, biosimilar (ruxience), 10 mg
Q5123	Injection, rituximab-arrx, biosimilar (riabni), 10mg

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Definitions & Policy Terms

Preferred oncology product: A UnitedHealthcare-designated product that is preferred for coverage; members new to therapy are required to use a preferred oncology product unless they meet the Preferred Product Criteria. (Policy Number: 2026D0030AQ; scope: defines coverage parameters for injectable oncology medications based primarily on NCCN categories and FDA labeling.)

Non-preferred oncology product: A product considered non-preferred; coverage is allowed only when both: (1) there is a history of intolerance or contraindication to one of UnitedHealthcare's preferred oncology products, and (2) the treating physician attests that the same intolerance/contraindication or adverse event would not be expected to occur with the non-preferred product. (Policy Number: 2026D0030AQ; scope: lists preferred and non-preferred products and applicable J-/HCPCS codes.)

Evidence sources: Primary compendium source is the NCCN Drugs & Biologics Compendium. When an NCCN Compendium entry is absent for an indication, the policy relies on FDA labeling as the basis for coverage determinations.

Clinical Evidence & Guidance Hierarchy

Evidence hierarchy and application: UnitedHealthcare gives priority to NCCN Compendium recommendations, accepting indications supported by NCCN Categories 1, 2A, or 2B as proven and medically necessary. The policy explicitly treats NCCN Category 3 recommendations as unproven and not medically necessary.

When no NCCN Compendium entry exists for a drug/indication, the policy instructs reviewers to use FDA labeling to determine coverage. This approach reflects the policy's reliance on authoritative compendium guidance first, with FDA labeling as the prespecified fallback.

Medicare Determinations / Related Coverage

Medicare-related determinations: Medicare does not have an NCD addressing preferred vs non-preferred cancer medications, but does have an NCD for chemotherapy — Anti-Cancer Chemotherapy for Colorectal Cancer — NCD 110.17. The policy also references applicable LCDs/LCAs and Medicare guidance when relevant.

Policy Revision History

2026-04-01revisedLatest

Revised list of UnitedHealthcare preferred and non-preferred oncology products; added specific product-level changes including Beizray (docetaxel J9174) as non-preferred, Carboplatin (J9045) as preferred, Jobevne (bevacizumab‑nwgd) as non-preferred, Kyxata as non-preferred, and other preferred/non-preferred designations across indications; added HCPCS/J-codes J9045, J9174, and J9275 to Applicable Codes.

2026-04-01added

Added language that coverage determinations shall be based upon U.S. FDA labeling when there is no NCCN Drugs & Biologics Compendium entry.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOncology Medication Clinical Coverage – Commercial Medical Benefit Drug Policyopen_in_new

Policy CodePolicy 2026D0030AQ

Change TypePreferred/non-preferred list updatedcodes addedcoverage basis clarified

Effective DateApr 1, 2026

Next Review Date

SourceLink

On This Page

Documentation Required

Document Evidence Source

When requesting coverage based on evidence outside the NCCN Compendium, include supporting documentation: cite the NCCN Evidence Category when available; if an NCCN entry with category is not available, provide applicable FDA labeling that supports the requested use.

Document the NCCN Drugs & Biologics Compendium evidence category (1, 2A, 2B) that supports the indication when available.
If the NCCN Compendium does not address the indication, provide relevant FDA labeling that supports the requested use.

Documentation Required

Pediatrics Coverage Note

All chemotherapy agents for individuals under age 19 years will be covered for oncology indications. For pediatric requests, indicate the member's age and, when applicable, reference national pediatric treatment protocol or guideline supporting the request.

Document the member's age (<19 years) on the prior authorization request to apply automatic pediatric chemotherapy coverage.
Include any pediatric protocol or guideline references when available to assist clinical review.