CurrentUnitedHealthcarePolicy CSOH2026D0030.D

Oncology Medication Clinical Coverage (for Ohio Only)

Defines coverage parameters for injectable oncology medications and therapeutic radiopharmaceuticals under the medical benefit for UnitedHealthcare members in Ohio, including preferred and non-preferred products and reliance on the NCCN Drugs & Biologics Compendium. Applies to providers requesting coverage for these drugs and to benefit determinations under Ohio rules.

Policy Summary

PayerUnitedHealthcare

PolicyOncology Medication Clinical Coverage (for Ohio Only)

Policy CodePolicy CSOH2026D0030.D

Change TypeRevised preferred/non-preferred product listHCPCS additions

Effective DateFeb 1, 2026

Next Review Date

Key ActionWhen requesting a non-preferred product, provide documentation of intolerance/contraindication to the preferred product and a physician attestation that the same issue would not be expected with the non-preferred product.

SourceLink

POLICY UPDATE CHANGES

Revised list of UnitedHealthcare preferred and non-preferred oncology products for all oncology indications and added Avgemsi (non-preferred) and gemcitabine (HCPCS codes J9196 and J9201) (preferred).

NCCN 1/2A/2BCompendium evidence levels accepted as proven

Category 3Not medically necessary (Category)

Ohio-onlyGeographic scope

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Coverage Criteria

General coverage criteria (preferred and indication-based)

Covered when ALL of the following are met

NCCN-based indication: The drug or biologic is listed in the NCCN Drugs & Biologics Compendium with a Category of Evidence and Consensus of 1, 2A, or 2B for the specific cancer indication.NCCN category in {1,2A,2B}

Categories 1/2A/2B are accepted as proven indications per policy.

Product preference: If a UnitedHealthcare preferred oncology product exists for the requested agent, coverage is for the preferred product unless the Preferred Product Criteria for non-preferred products are met.Preferred product available

Preferred and respective non-preferred products are listed in the Oncology Products table.

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

Pediatric patients are commonly treated per national pediatric protocols.

Preferred Product Criteria

Non-preferred product coverage (must meet ALL):

Intolerance or contraindication: History of intolerance or contraindication to one of UnitedHealthcare's preferred oncology products.Documented history

Provider must document the adverse event or contraindication.

Physician attestation: 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.Signed attestation

Required for approval of a non-preferred product.

This policy does not provide coverage criteria for Chimeric Antigen Receptor (CAR)-T Cell or Tumor-Infiltrating Lymphocyte (TIL) Cell products. Coverage determinations for those therapies are made under applicable transplant-related criteria and the OptumHealth Transplant Solutions clinical guideline referenced in this policy.

Indications that are supported only by an NCCN Category 3 designation are considered unproven and not medically necessary under this policy. Category 3 reflects major disagreement among panel members about interpretation or generalizability of the evidence and therefore does not meet the policy’s threshold for proven indications.

Coding and Billing

Applicable HCPCS Codes (reference list)HCPCS

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.
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 chemotherapy coverage age

Pediatric chemotherapy coverage ageAll chemotherapy agents will be 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 guidelines.

Applicable scopeApplies to chemotherapy agents covered under the medical benefit per this policy.

Provider Actions and Prior Authorization

Prior Authorization

Prior authorization and product preference rules

Coverage for UnitedHealthcare-preferred oncology products is contingent on meeting the Diagnosis-Specific Criteria; coverage for any listed non-preferred oncology product is contingent on meeting BOTH the Preferred Product Criteria and the Diagnosis-Specific Criteria.

Preferred products: covered when Diagnosis-Specific Criteria are met.
Non-preferred products: require meeting Preferred Product Criteria AND Diagnosis-Specific Criteria.

Step Therapy

Preferred product sequencing

UnitedHealthcare designates certain products as preferred; providers must request preferred products first and obtain authorization for them by demonstrating the Diagnosis-Specific Criteria are met.

Examples: leucovorin preferred over levoleucovorin; gemcitabine (J9201, J9196) preferred over Avgemsi; irinotecan preferred over Onivyde for pancreatic cancer; teclistamab preferred over elranatamab for multiple myeloma.

Background

This policy defines coverage parameters for injectable oncology medications and therapeutic radiopharmaceuticals furnished under the medical benefit for UnitedHealthcare members in Ohio. Coverage is determined by whether the drug or biologic and the requested indication are listed in the NCCN Drugs & Biologics Compendium with an accepted evidence category (NCCN Categories 1, 2A, or 2B) and by product preference rules described in the policy. The policy also specifies that all chemotherapy agents will be covered for individuals under 19 years of age for oncology indications and that therapeutic radiopharmaceuticals (for example, iobenguane I‑131, lutetium Lu‑177 dotatate, radium‑223) are drugs containing radioactive material that selectively accumulate in tumors to deliver cytotoxic radiation.

Definitions

Therapeutic radiopharmaceuticals — definition and examples

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

Examples (from policy text)Azedra (iobenguane I‑131); Lutathera (lutetium Lu‑177 dotatate); Xofigo (radium‑223).

Context of useTherapeutic radiopharmaceuticals are included among injectable oncology medications covered under the medical benefit per the NCCN Compendium guidance.

Preferred and Non-Preferred Regimens

Preferred product	Non-preferred equivalent	Indication	Coverage status
Leucovorin	Levoleucovorin	All oncology indications	Preferred

Preferred product (HCPCS)	Non-preferred equivalent	Indication	Coverage status
Gemcitabine (J9201, J9196)	Avgemsi	All oncology indications	Preferred

Preferred product	Non-preferred equivalent	Indication	Coverage status
Irinotecan	Onivyde (irinotecan liposome)	Pancreatic cancer	Preferred

Preferred product	Non-preferred equivalent	Indication	Coverage status
Tecvayli (teclistamab-cqyv)	Elrexfio (elranatamab-bcmm)	Multiple myeloma	Preferred