CurrentUnitedHealthcarePolicy CSLA2026D0030AD

Oncology Medication Clinical Coverage (for Louisiana Only)

UnitedHealthcare Louisiana Medical Benefit Drug Policy governing coverage parameters for injectable oncology medications and therapeutic radiopharmaceuticals (medical benefit) including preferred and non-preferred product designations and diagnosis-specific criteria tied to NCCN Compendium categories of evidence.

Policy Summary

PayerUnitedHealthcare

PolicyMedical Benefit Drug Policy

Policy CodePolicy CSLA2026D0030AD

Change TypePreferred and non-preferred product list updates; applicable code added

Effective DateJan 1, 2026

Next Review Date

Key ActionWhen requesting a non-preferred oncology product, document history of intolerance/contraindication to a preferred product and provide physician attestation that the same adverse event would not be expected with the non-preferred product.

POLICY UPDATE CHANGES

Added Imjudo (tremelimumab-actl) + Imfinzi (durvalumab) as preferred for hepatocellular carcinoma: combination systemic therapy.

Added Opdivo (nivolumab) + Yervoy (ipilimumab) as non-preferred for hepatocellular carcinoma: combination systemic therapy.

Added Tecentriq + any of Avastin, Zirabev, Alymsys, Vegzelma as non-preferred for hepatocellular carcinoma: combination systemic therapy.

Added Tecentriq + Mvasi and Tecentriq Hybreza + Mvasi as preferred for hepatocellular carcinoma: combination systemic therapy.

Replaced head and neck cancers indication wording to 'head and neck cancers: cancer of the nasopharynx, recurrent, unresectable, oligometastatic, or metastatic disease, nasopharyngeal'.

Added HCPCS code J9289 to Applicable Codes.

List updatedPreferred and Non-Preferred product lists revised

1/2A/2BEvidence-based coverage stance: NCCN Categories covered

Louisiana

Coverage Summary

Scope: This policy governs UnitedHealthcare Louisiana medical-benefit coverage for injectable oncology medications and therapeutic radiopharmaceuticals (medical benefit), including preferred and non-preferred product designations and diagnosis-specific criteria tied to the NCCN Drugs & Biologics Compendium. Geographic scope is Louisiana-only. Effective date and last review: January 1, 2026.

Coverage stance: The policy aligns coverage determinations to NCCN Drugs & Biologics Compendium categories. NCCN Categories 1, 2A, and 2B are considered proven and medically necessary (subject to benefit considerations and member benefits); NCCN Category 3 is considered not medically necessary.

Pediatric and transplant notes: UnitedHealthcare will cover all chemotherapy agents for individuals under 19 years for oncology indications. CAR-T and TIL products are not covered under this policy and are handled under the Transplantation Services benefit per OptumHealth Transplant Solutions criteria.

Preferred Product / Initial Therapy Criteria

Preferred Product Criteria (Non-Preferred product use allowed)

Treatment with the respective non-preferred product is medically necessary for oncology indications when BOTH of the following are met:

ALL of the following

History of intolerance or contraindication to one of UnitedHealthcare's preferred oncology products
Physician attests that, in their clinical opinion, the same intolerance, contraindication, or adverse event would not be expected to occur with the respective non-preferred product

Diagnosis-Specific Criteria (NCCN Categories)

Diagnosis-Specific Criteria

Coverage determinations based on NCCN Drugs & Biologics Compendium Categories of Evidence and Consensus:

Coverage by NCCN category

Categories of Evidence and Consensus 1, 2A, 2B are considered proven and medically necessary (subject to Benefit Considerations and member benefits)
Category 3 is considered unproven and not medically necessary

Pediatric coverage: UnitedHealthcare will cover all chemotherapy agents for individuals under the age of 19 years for oncology indications

Applicable Codes

Therapeutic radiopharmaceutical HCPCS (referenced)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 and relevant HCPCS Q-codesmixed

J0640	Injection, leucovorin calcium, per 50 mg
J0641	Injection, levoleucovorin, not otherwise specified, 0.5 mg
J0642	Injection, levoleucovorin (Khapzory), 0.5 mg
J1323	Injection, elranatamab-bcmm, 1 mg
J3263	Injection, toripalimab-tpzi, 1 mg
J9022	Injection, atezolizumab, 10 mg
J9024	Injection, atezolizumab, 5 mg and hyaluronidase-tqjs
J9035	Injection, bevacizumab, 10 mg
J9041	Injection, bortezomib, 0.1mg
J9049	Injection, bortezomib, hospira, 0.1 mg

1–10 of 55

1/6

Provider Actions & Prior Authorization Requirements

Prior Authorization

Prior Authorization Required

Coverage contingent on NCCN Drugs & Biologics Compendium Category (1, 2A, 2B) and member benefits; check state/contractual requirements and the Louisiana Medicaid Preferred Drug List/Non-Preferred Drug List (PDL/NPDL) for outpatient pharmacy coverage.

Documentation Required

Documentation Required for Non-Preferred Oncology Products

When requesting a non-preferred oncology product, the provider must document a history of intolerance or contraindication to the preferred product and include a physician attestation that, in their clinical opinion, the same adverse event or intolerance would not be expected to occur with the requested non-preferred product.

Definitions

Preferred Oncology Product: UnitedHealthcare-designated oncology drug listed as preferred in the Oncology Products table; outpatient retail coverage may be governed by state PDL/NPDL.

Non-Preferred Oncology Product: Products designated non-preferred in the Oncology Products table; may be covered if Preferred Product Criteria are met.

Clinical Evidence & Guiding Framework

Evidence basis: This policy aligns medical-benefit coverage to the NCCN Drugs & Biologics Compendium and implements coverage determinations based on the Compendium's Categories of Evidence and Consensus.

NCCN categories considered medically necessary: 1, 2A, 2B. NCCN category considered not medically necessary: 3.

The policy references the NCCN Guidelines as the evidence framework; Category definitions (1, 2A, 2B, 3) describe levels of evidence and consensus that inform coverage decisions.

Background / Policy Context

Background: The policy provides parameters for coverage of injectable oncology medications (including examples such as octreotide acetate, leucovorin, and levoleucovorin) and therapeutic radiopharmaceuticals under the medical benefit based upon the NCCN Drugs & Biologics Compendium. The Compendium lists appropriate drugs and biologics for specific cancers using FDA-approved indications and NCCN panel recommendations.

UnitedHealthcare recognizes NCCN Categories of Evidence and Consensus 1, 2A, and 2B as proven and medically necessary and Category 3 as unproven and not medically necessary. Coverage is subject to benefit considerations and member-specific benefits.

UnitedHealthcare will cover all chemotherapy agents for individuals under the age of 19 years for oncology indications. Chimeric Antigen Receptor (CAR)-T Cell Therapy and tumor-infiltrating lymphocyte (TIL) cell products are not covered by this policy and may be eligible under a member's Transplantation Services benefit per OptumHealth Transplant Solutions criteria.

Applicability and location: This Medical Benefit Drug Policy applies only to the state of Louisiana. The policy history notes material changes effective 01/01/2026 including updates to preferred and non-preferred product lists and addition of HCPCS code J9289.

Revision History

2026-01-01addedLatest