CurrentUnitedHealthcarePolicy CSIND0030.13

Oncology Medication Clinical Coverage (for Indiana Only)

Defines UnitedHealthcare Community Plan's medical benefit coverage parameters for injectable oncology medications (including therapeutic radiopharmaceuticals) in the state of Indiana, based primarily on NCCN Drugs & Biologics Compendium categories of evidence. Excludes CAR-T and TIL products (handled under transplant/OptumHealth Transplant Solutions criteria).

Policy Summary

PayerUnitedHealthcare

PolicyOncology Medication Clinical Coverage (for Indiana Only)

Policy CodePolicy CSIND0030.13

Change TypeRoutine review; no content changes

Effective DateJan 1, 2026

Next Review Date

Key ActionProviders should ensure the injectable oncology medication and intended use are supported by the NCCN Drugs & Biologics Compendium with Category 1, 2A, or 2B evidence to meet coverage criteria.

SourceLink

POLICY UPDATE CHANGES

01/01/2026, Summary of Changes = Routine review; no content changes

3NCCN Categories Considered Covered

1NCCN Category Considered Not Medically Necessary

19Pediatric Coverage Age Threshold (years)

Coverage Summary

Coverage is based on the NCCN Drugs & Biologics Compendium for injectable oncology medications in Indiana; Category 1/2A/2B are covered when criteria are met, Category 3 is not medically necessary, pediatric exceptions apply for members under 19, and CAR‑T/TIL products are excluded from this policy and evaluated under transplant criteria.

Providers must include documentation demonstrating the NCCN Compendium listing and category, the specific oncology indication, and evidence of Indiana UnitedHealthcare membership for the member. For pediatric patients (<19 years), include the pediatric oncology indication and treatment protocol when available. CAR‑T/TIL requests should follow the transplant benefit submission process.

Diagnosis-Specific Criteria for Injectable Oncology Medications

Covered when ALL of the following are met:

ALL of the following

Medication and specific indication are listed in the NCCN Drugs & Biologics Compendium with Category of Evidence & Consensus 1, 2A, or 2B.
Request is for an oncology indication consistent with the NCCN Compendium entry (including therapeutic radiopharmaceuticals when listed).
Member is enrolled with UnitedHealthcare in the state of Indiana.

Pediatric Exception

Covered when ALL of the following are met (pediatric exception):

ALL of the following

Member age is under 19 years at time of request (< 19 years).
Medication is being used for a pediatric oncology indication.
Documentation provided includes pediatric treatment protocol or treating institution plan when available.

CAR-T and TIL Products

Exclusions and alternative pathway:

Chimeric Antigen Receptor (CAR)-T Cell Therapy and Tumor-Infiltrating Lymphocyte (TIL) Cell Therapy are excluded from the coverage criteria in this Medical Benefit Drug Policy.

Coverage determinations for CAR-T and TIL are made under the member's Transplantation Services benefit and per OptumHealth Transplant Solutions clinical guidelines titled 'Chimeric Antigen Receptor T-Cell (CAR T) Therapy' and 'Tumor-Infiltrating Lymphocyte (TIL) Cell Therapy'. Providers should submit CAR-T/TIL coverage requests through the transplant/medical benefit pathway with required transplant documentation.

Provider Actions / Prior Authorization

Documentation Required

Reference NCCN Compendium Category

Ensure the injectable oncology medication and the intended use are supported by the NCCN Drugs & Biologics Compendium with a Category of Evidence and Consensus of 1, 2A, or 2B to meet coverage criteria.

Documentation Required

Pediatric coverage confirmation

For members under age 19, document the oncology indication as chemotherapy to support coverage under this policy.

Prior Authorization

CAR-T / TIL coverage pathway

Do not pursue coverage for CAR‑T or TIL products under this medical benefit drug policy. Instead follow the OptumHealth Transplant Solutions criteria and the Transplantation Services benefit processes (Clinical Guideline: Chimeric Antigen Receptor T‑Cell (CAR T) Therapy / TIL Cell Therapy) for prior authorization and coverage determinations.

Background & Definitions

UnitedHealthcare bases coverage for injectable oncology medications on the NCCN Drugs & Biologics Compendium and aligns its approach with the NCCN Clinical Practice Guidelines in Oncology. Therapeutic radiopharmaceuticals are defined as medications that contain radioactive material which selectively accumulates within tumors and releases radiation to kill cancer cells. Coverage for CAR‑T and TIL products is not addressed in this drug policy and is instead considered under the member's Transplantation Services benefit per OptumHealth Transplant Solutions criteria and the Clinical Guideline titled Chimeric Antigen Receptor T‑Cell (CAR T) Therapy.

Term	Definition
Category 1
The recommendation is based on high-level evidence (i.e., high-powered randomized clinical trials or meta-analyses), and the panel has reached uniform consensus that the recommendation is indicated.
Category 2A
The recommendation is based on lower-level evidence, but despite the absence of higher-level studies, there is uniform consensus that the recommendation is appropriate.
Category 2B
The recommendation is based on lower-level evidence, and there is nonuniform consensus that the recommendation should be made; multiple approaches may be reasonable.
Category 3
The recommendation has engendered a major disagreement among the panel members and is considered unproven and not medically necessary per this policy.
Therapeutic radiopharmaceuticals
Medications that contain radioactive material that selectively accumulate within tumors to release radiation and kill cancer cells.

Clinical Evidence & References

Primary evidence for coverage decisions is the NCCN Drugs and Biologics Compendium. UnitedHealthcare uses the Compendium’s Categories of Evidence and Consensus to determine coverage categories: indications listed with Categories 1, 2A, and 2B are considered proven and covered, while Category 3 is considered unproven and not medically necessary.