CurrentUnitedHealthcarePolicy N/A

Medical Benefit Therapeutic Equivalent Medications Excluded Drug List with Preferred Alternatives

Defines UnitedHealthcare commercial medical-benefit medications deemed therapeutically equivalent and excluded from coverage, with required preferred alternatives and applicable HCPCS/other billing codes; applies to UnitedHealthcare Commercial plans and affiliates.

Policy Summary

PayerUnitedHealthcare

PolicyMedical Benefit Therapeutic Equivalent Medications Excluded Drug List with Preferred Alternatives

Policy CodePolicy N/A

Change TypeUpdated exclusions & preferred alternatives (2023-2026)

Effective DateApr 1, 2026

Next Review Date

Key ActionReview the member-specific benefit plan document and federal/state requirements before applying exclusions; member document supersedes this policy if conflicting.

SourceLink

POLICY UPDATE CHANGES

Updated list of preferred alternatives for Beovu® and Byooviz™; added Eylea HD® and Pavblu™.

Updated list of related policies and updated excluded medications: added Azmiro™ (J1072), Daxxify® (J0589), Jubbonti® (Q5136).

Added Alyglo™ (J1552) to exclusions and removed Cutaquig® (J1551) from exclusions; modified preferred alternatives for Asceniv™ and Panzyga® (IV).

Updated excluded medications including additions/removals (e.g., Beovu®, Byooviz™, Cuvitru®) and HCPCS code updates (added J1576; removed 90283 and J1599).

~30+Listed Excluded Medications (approx.)

MultiplePreferred Alternatives per excluded product

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Policy summary

This list identifies healthcare provider‑administered, medical‑benefit medications that UnitedHealthcare's Pharmacy & Therapeutics (P&T) Committee has deemed therapeutically equivalent and therefore excluded from coverage when listed. It is supported by the Medical Benefit Drug Policy titled "Medical Benefit Therapeutic Equivalent Medications - Excluded Drugs."

UnitedHealthcare defines Therapeutic Equivalence for this policy as medications/products having "essentially the same efficacy and adverse effect profile" as determined by the UnitedHealthcare P&T Committee; this is a payer‑specific definition and is not intended to imply equivalence as defined by the FDA Orange Book.

The list and exclusions apply to UnitedHealthcare Commercial plan members, including All Savers and affiliate plans. When evaluating coverage for an excluded medical‑benefit medication, reviewers must first confirm member eligibility and review the member‑specific benefit document (e.g., Certificate of Coverage, Schedule of Benefits, Summary Plan Description), because the member‑specific plan document supersedes this list if there is a conflict. Excluded medications are generally not covered while listed, and preferred alternatives are recommended/prior authorization considerations where noted.

Dates, Status, and Key Stats

Effective date2026-04-01

Last review2026-04-01

Next review

Coverage stancemixed (exclusions with preferred alternatives)

StatusCURRENT

Listed Excluded Medications (approx.)~30+

Preferred Alternatives per excluded productMultiple (varies by product)

Notable oncology exceptionJubbonti® exclusion applies only to non-oncology use (1 exception)

Coverage rules & application

General Application / Therapeutic Equivalence Exclusion

Excluded when ALL of the following apply:

Medication listed on Excluded Medications List: Medication is a healthcare provider administered medical benefit medication listed on the Excluded Medications List
Deemed therapeutically equivalent by P&T: Medication has been deemed therapeutically equivalent by the UnitedHealthcare Pharmacy and Therapeutics (P&T) Committee
Therapeutic equivalence per policy means essentially the same efficacy and adverse effect profile as determined by the UnitedHealthcare P&T Committee (not the FDA Orange Book).
Applies to UnitedHealthcare Commercial plans: Member is covered under UnitedHealthcare Commercial plans including All Savers and affiliate plans

HCPCS / billing codes

The codes listed below are medical-benefit HCPCS/Q codes where provided in the source. Some preferred alternative medications noted in the list may not have HCPCS codes listed in the brief or may be billed under different codes depending on product, formulation, or site of care. Confirm the exact billing HCPCS/Q codes for the product and UnitedHealthcare plan prior to claim submission.

Actions required of providers / prior authorization guidance

Documentation Required

Verify member-specific benefit and eligibility

Review the member-specific benefit plan document (e.g., Certificate of Coverage, Schedule of Benefits, Summary Plan Description) and any applicable federal or state requirements before applying exclusions. If the member-specific benefit plan document conflicts with this policy, the member document supersedes the policy.

Prior Authorization

Try preferred alternatives before requesting excluded medication

Prescribers must try the listed preferred alternative(s) for the specific excluded medication before requesting coverage of the excluded product, unless the excluded-medication entry explicitly states otherwise.

Preferred alternatives vary by excluded product and are specified on the medication list for each entry.

Key definitions

Definitions

Therapeutic Equivalence (per policy)Medications/products have essentially the same efficacy and adverse effect profile as determined by the UnitedHealthcare P&T Committee (not equivalent to FDA Orange Book definition).

Document revision timeline

2023-2024revised

Updated excluded medications including additions/removals (e.g., Beovu®, Byooviz™, Cuvitru®) and HCPCS code updates (added J1576; removed 90283 and J1599).

Exception / Preferred Alternatives Requirement

When an excluded medication is requested, coverage requires that ALL of the following be considered:

Prescriber must try preferred alternatives: Prescriber must try the listed preferred alternative(s) unless noted otherwise for the specific excluded medication
Preferred alternatives are listed per excluded medication (examples: ophthalmologic VEGF alternatives for Beovu/Byooviz include Avastin, Cimerli, Eylea, Eylea HD, Lucentis, Pavblu, Vabysmo).
Identify federal/state and member-specific requirements: Any federal or state regulatory requirements and member-specific coverage must be identified prior to applying exclusion
Member-specific benefit plan document supersedes this policy if conflicting; reviewers must identify member eligibility and requirements first.

Documentation actions: Review the member-specific benefit plan document (COC/SOB/SPD) and federal/state requirements before applying exclusions; document attempts of preferred alternatives when required

Prescribers must try listed preferred alternatives for the specific excluded medication unless an entry explicitly states otherwise.