CurrentUnitedHealthcarePolicy CSPA2025D0030GG

Oncology Medication Clinical Coverage (injectable oncology medications and therapeutic radiopharmaceuticals) (for Pennsylvania Only)

Defines UnitedHealthcare Community Plan coverage parameters for injectable oncology medications (including therapeutic radiopharmaceuticals) for Pennsylvania members, referencing NCCN Drugs & Biologics Compendium recommendations and a preferred/non-preferred product list.

Policy Summary

PayerUnitedHealthcare

PolicyOncology Medication Clinical Coverage (injectable oncology medications and therapeutic radiopharmaceuticals) (for Pennsylvania Only)

Policy CodePolicy CSPA2025D0030GG

Change TypeRevised preferred/non-preferred product list

Effective DateDec 1, 2025

Next Review Date

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

SourceLink

POLICY UPDATE CHANGES

Revised list of UnitedHealthcare preferred and non-preferred oncology products; added several preferred combination regimens for hepatocellular carcinoma and specified certain non-preferred combinations.

Preferred + Non-PreferredNumber of named injectable oncology products and biosimilars listed

Categories 1/2A/2B coveredNCCN evidence categories and coverage stance

Pennsylvania

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Coverage criteria & decision logic

General Coverage Determination based on NCCN Compendium

Injectable oncology medications and therapeutic radiopharmaceuticals are covered when recommendations are supported by the NCCN Drugs & Biologics Compendium with the following evidence categories:

ANY of the following

NCCN Categories of Evidence & Consensus 1, 2A, or 2B
Considered proven and medically necessary (subject to benefit and other policy sections).
NCCN Category of Evidence & Consensus 3
Considered unproven and not medically necessary.

Pediatric rule

All chemotherapy agents for individuals under 19 years for oncology indications
Covered (policy states coverage for all chemotherapy agents under age 19).

Preferred Product Criteria (use of non-preferred oncology product)

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

ALL of the following

History of intolerance or contraindication to the UnitedHealthcare preferred oncology product
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

Preferred vs Non-Preferred product logic & exceptions

Coverage for preferred and non-preferred oncology products is applied as follows:

ALL of the following

Preferred product requested
Coverage provided when Diagnosis-Specific Criteria are met.
Non-preferred product requested
Coverage provided only if Preferred Product Criteria AND Diagnosis-Specific Criteria are met.

Relevant billing codes

Therapeutic radiopharmaceutical HCPCSHCPCS

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

Injectable oncology J-codes (selected)HCPCS

J0640	Injection, leucovorin calcium, 50 mg
J0641	Injection, levoleucovorin, NOS, 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, 0.1 mg
J9049	Injection, bortezomib, Hospira, 0.1 mg

1–10 of 42

1/5

Biosimilar Q-codesHCPCS

Q5107	Injection, bevacizumab-awwb (Mvasi), biosimilar, 10 mg
Q5112	Injection, trastuzumab-dttb (Ontruzant), biosimilar, 10 mg
Q5113	Injection, trastuzumab-pkrb (Herzuma), biosimilar, 10 mg
Q5114	Injection, trastuzumab-dkst (Ogivri), biosimilar, 10 mg
Q5115	Injection, rituximab-abbs (Truxima), biosimilar, 10 mg
Q5116	Injection, trastuzumab-qyyp (Trazimera), biosimilar, 10 mg
Q5117	Injection, trastuzumab-anns (Kanjinti), biosimilar, 10 mg
Q5118	Injection, bevacizumab-bvzr (Zirabev), biosimilar, 10 mg
Q5119	Injection, rituximab-pvvr (Ruxience), biosimilar, 10 mg
Q5123	Injection, rituximab-arrx (Riabni), biosimilar, 10 mg

1–10 of 12

1/2

What providers must do

Documentation Required

Physician attestation for non-preferred product

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

Document history of intolerance or contraindication to the UnitedHealthcare preferred oncology product.
Provide physician attestation that the same intolerance/contraindication/adverse event would not be expected with the non-preferred product.

Prior Authorization

Coverage contingent on Diagnosis-Specific Criteria

Coverage for preferred oncology products is provided contingent on meeting the Diagnosis‑Specific Criteria in this policy; coverage for non‑preferred products requires meeting both the Preferred Product Criteria and the Diagnosis‑Specific Criteria. Requests that do not meet these criteria will be reviewed for medical necessity on a case‑by‑case basis.

Clinical and policy context

This policy uses the NCCN Drugs & Biologics Compendium as the basis for determining medical necessity for injectable oncology medications and therapeutic radiopharmaceuticals covered under the medical benefit. Recommendations in the Compendium are classified by Categories of Evidence & Consensus; the policy recognizes Category 1, 2A, and 2B recommendations as proven and medically necessary (subject to benefit and other policy provisions), while Category 3 recommendations are considered unproven and not medically necessary.

The policy lists UnitedHealthcare preferred and non-preferred oncology products (including biosimilars) and specifies that coverage for a UnitedHealthcare preferred oncology product is provided when the Diagnosis-Specific Criteria are met. Coverage for a non-preferred oncology product is available only when the Preferred Product Criteria are met — specifically, documentation of a history of intolerance or contraindication to the preferred product and a physician attestation that the same intolerance/contraindication/adverse event would not be expected with the requested non-preferred product — in addition to meeting the Diagnosis-Specific Criteria.

Chimeric Antigen Receptor (CAR)-T cell and Tumor-Infiltrating Lymphocyte (TIL) therapies are not covered under this medical benefit drug policy; coverage determinations for these products are handled under transplant benefits and the OptumHealth Transplant Solutions criteria (see the Clinical Guideline titled "Chimeric Antigen Receptor T-cell Therapy").

Defined terms

Definitions

Preferred Product CriteriaPolicy rule that allows coverage of a non-preferred product only if the member has a history of intolerance or contraindication to the UnitedHealthcare preferred product and the physician attests that the same intolerance/contraindication/adverse event would not be expected to occur with the non-preferred product.

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

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

NCCN Category 2BRecommendation based on lower-level evidence with nonuniform consensus; multiple reasonable approaches may exist due to inconclusive evidence.

NCCN Category 3Recommendation that has engendered major disagreement among panel members and is considered unproven and not medically necessary for coverage purposes.

What changed in this version

12/01/2025policy_revisionLatest

Revised list of UnitedHealthcare preferred and non-preferred oncology products: added preferred combination regimens for hepatocellular carcinoma (Tecentriq + Mvasi; Tecentriq Hybreza + Mvasi; Imjudo + Imfinzi), marked certain Tecentriq combinations with Avastin biosimilars and Opdivo + Yervoy as non-preferred, updated head & neck cancer indication wording, added HCPCS J9289 and revised the description for Q5146; this change is material.