CurrentUnitedHealthcarePolicy N/A

Prior authorization for select oral chemotherapeutic agents

Defines pharmacy benefit coverage and prior authorization/notification criteria for select oral oncology medications, based on NCCN Drugs & Biologics Compendium categories and FDA labeling; includes special rule for members under 19 and authorizations issued for 12 months. Effective for UnitedHealthcare pharmacy clinical programs.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization for select oral chemotherapeutic agents

Policy CodePolicy N/A

Change TypeAnnual review; effective date updated

Effective DateMar 1, 2025

Next Review Date

Key ActionSubmit authorization requests that meet the coverage criteria; authorizations will be issued for 12 months and members under age 19 will process automatically without coverage review.

POLICY UPDATE CHANGES

Program annual reviews noted with no changes to coverage criteria on multiple dates including 11/2020, 11/2021, 10/2023, and 12/2024.

Effective date updated to 2025-03-01.

3Coverage pathways

12 moAuthorization duration

yesAuto approval: <19

Coverage Summary

This policy defines pharmacy benefit coverage and prior authorization criteria for select oral chemotherapeutic agents and is in effect beginning 2025-03-01. Coverage is covered with criteria; authorizations are issued for 12 months when criteria are met. UnitedHealthcare aligns coverage of oral oncology medications with the NCCN Drugs & Biologics Compendium and interprets NCCN evidence categories in its coverage determinations.