CurrentUnitedHealthcarePolicy CSOH2026D0030.E

Oncology Medication Clinical Coverage (for Ohio Only)

Defines UnitedHealthcare Ohio coverage parameters for injectable oncology medications (including therapeutic radiopharmaceuticals) guided by the NCCN Drugs & Biologics Compendium; applies to Ohio members and providers requesting medical-benefit oncology drugs.

Policy Summary

PayerUnitedHealthcare

PolicyOncology Medication Clinical Coverage (for Ohio Only)

Policy CodePolicy CSOH2026D0030.E

Change TypeAdded code

Effective DateMay 1, 2026

Next Review Date

Key ActionSubmit documentation showing history of intolerance or contraindication to the preferred product plus physician attestation when requesting a non-preferred oncology product.

SourceLink

POLICY UPDATE CHANGES

Added HCPCS code J9184 to the Applicable Codes list.

NCCN 1/2A/2BEvidence categories

OhioApplies to

<19Pediatric cutoff

TablePref/non-pref

Coverage Criteria for Injectable Oncology Drugs

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General coverage criteria for injectable oncology drugs

Covered when ALL of the following are met

Primary coverage basis: Indication is supported by the NCCN Drugs & Biologics Compendium with Categories of Evidence and Consensus 1, 2A, or 2B.NCCN Category 1, 2A, or 2B

References NCCN Compendium

Preferred product use: Use UnitedHealthcare preferred oncology product per the Oncology Products table unless criteria for a non-preferred product are met.preferred product available

See Oncology Products table and Preferred Product Criteria

Non-preferred product exception: Non-preferred product is medically necessary only when there is a history of intolerance or contraindication to the preferred product AND the physician attests the same intolerance/adverse event would not be expected with the non-preferred product.history of intolerance/contraindication + physician attestation

See Preferred Product Criteria and Instructions for Use

Pediatric coverage: All chemotherapy agents are covered for individuals under age 19 for oncology indications.age < 19 years

Pediatric protocols aligned with NCCN guidance

This policy does not provide coverage criteria for Chimeric Antigen Receptor (CAR)-T Cell or Tumor-Infiltrating Lymphocyte (TIL) Cell products. Coverage determinations for CAR‑T (and related cellular therapies) are made according to the member's benefits and the OptumHealth Transplant Solutions criteria; see the Clinical Guideline titled "Chimeric Antigen Receptor T-Cell (CAR T) Therapy" for Ohio-specific transplant benefit considerations.

Indications listed in the NCCN Drugs & Biologics Compendium with Category 3 (major disagreement) are considered unproven and not medically necessary and may be denied per the policy's coverage stance.

Preferred product	Non‑preferred product	Indications / Notes
Gemcitabine (J9201, J9196)
Avgemsi
All oncology indications

Applicable Codes and Pediatric Age

Applicable HCPCS/J-codesHCPCS

J0640	Injection, leucovorin calcium, 50 mg.
J0641	Injection, levoleucovorin, not otherwise specified, 0.5 mg.
J0642	Injection, levoleucovorin (khapzory), 0.5 mg.
J1323	Injection, elranatamab-bcmm, 1 mg.
J9184	Injection, gemcitabine hydrochloride (avyxa), 200 mg.
J9196	Injection, gemcitabine hydrochloride (accord), 200 mg.
J9201	Injection, gemcitabine hydrochloride, 200 mg.
J9205	Injection, irinotecan liposome, 1 mg.
J9206	Injection, irinotecan, 20 mg.
J9380	Injection, teclistamab cqyv, 0.5 mg.

Pediatric age cutoff

Pediatric age cutoffAll chemotherapy agents are covered for individuals under the age of 19 years for oncology indications.

RationaleMajority of pediatric patients receive treatments on national pediatric protocols similar to NCCN patient care guidelines.

Applicable scopeApplies to oncology indications only; pediatric chemotherapy coverage is broad regardless of NCCN category.

Provider Requirements, Prior Authorization and Documentation

Prior Authorization

Prior Authorization and Coverage Dependency

Coverage for UnitedHealthcare preferred oncology products is contingent on meeting the Diagnosis-Specific Criteria. Prior authorization is required and coverage for a non-preferred oncology product is contingent on meeting BOTH the Preferred Product Criteria and the Diagnosis-Specific Criteria.

Coverage contingent on Diagnosis-Specific Criteria and Preferred Product rules
Prior authorization required for oncology products

Documentation Required

Preferred Product Requirement for Non-Preferred Use

A non-preferred oncology product may be approved only when the provider documents a history of intolerance or contraindication to the applicable UnitedHealthcare preferred oncology product AND the provider attests that, in their clinical opinion, the same intolerance/contraindication or adverse event would not be expected to occur with the non-preferred product.

History of intolerance or contraindication to the preferred product is required
Physician attestation that the same intolerance/contraindication/adverse event is not expected with the non-preferred product

Documentation Required

Documentation Requirements for Non-Preferred Products

When requesting a non-preferred oncology product, include documentation demonstrating prior use and intolerance/contraindication to the preferred product and the physician's clinical rationale/attestation supporting the non-preferred choice. Insufficient documentation may result in denial.

Document prior trial(s) of the preferred oncology product and specific intolerance/contraindication details
Include physician statement attesting the non-preferred product is unlikely to cause the same adverse event
Attach relevant clinical records, test results, and prior treatment notes

Denial Risk

Denial Risk for NCCN Category 3 Requests

Requests for uses categorized by NCCN as Category 3 are considered unproven and not medically necessary and may be denied.

NCCN Category 3 requests are high denial risk

Terms and Evidence Categories

Therapeutic radiopharmaceuticals

DefinitionMedications that contain radioactive material which selectively accumulate within tumors and release radiation to kill cancer cells.

ExamplesAzedra (iobenguane I 131), Lutathera (lutetium Lu 177 dotatate), Xofigo (radium-223).

Benefit contextTherapeutic radiopharmaceuticals are included among injectable oncology medications covered under the medical benefit per the NCCN Compendium framework.

NCCN Categories of Evidence and Consensus

Category 1Recommendation based on high-level evidence (e.g., high-powered randomized trials or meta-analyses) with uniform consensus that the recommendation is indicated.

Category 2ARecommendation based on lower level evidence but with uniform consensus that the recommendation is appropriate; evidence may include phase II studies, cohort studies, case series, or expert experience.

Category 2BRecommendation based on lower level evidence with nonuniform consensus; institutions may adopt different approaches given imperfect information.

Category 3Recommendation has engendered major disagreement among panel members and is considered unproven; indications listed as Category 3 are not medically necessary per this policy.

Policy Background

This policy uses the NCCN Drugs & Biologics Compendium to define appropriate injectable oncology drugs and therapeutic radiopharmaceuticals. The Compendium identifies drugs and biologics for specific cancers based on FDA‑approved disease indications and NCCN panel recommendations with assigned Categories of Evidence and Consensus; the policy recognizes indications with Categories 1, 2A, and 2B as proven and covered, while Category 3 is considered unproven and not medically necessary. Therapeutic radiopharmaceuticals are included within the scope of covered medical‑benefit injectable oncology medications.