CurrentUnitedHealthcarePolicy CSPA2026D0034AS

Maximum Dosage and Frequency (for Pennsylvania Only) – Community Plan Medical Benefit Drug Policy

This Pennsylvania-only UnitedHealthcare Community Plan medical benefit drug policy defines maximum dosage per administration and maximum dosing frequency (by HCPCS units and NDC billing quantities) for a large list of physician-administered medications, and states that dosing beyond these maxima is considered unproven or not medically necessary unless supported by labeling or clinical evidence or due to patient body size >95th percentile thresholds.

Policy Summary

PayerUnitedHealthcare

PolicyMaximum Dosage and Frequency (for Pennsylvania Only) – Community Plan Medical Benefit Drug Policyopen_in_new

Policy CodePolicy CSPA2026D0034AS

Change TypeRevised HCPCS/NDC limits and coverage rationale

Effective DateMay 1, 2026

Next Review Date

Key ActionEnsure administered dose per administration and frequency do not exceed the policy's maximum allowed HCPCS units or NDC maximums; document patient weight/BSA when doses approach limits and provide evidence if exceeding labeled maxima (e.g., clinical evidence or patient body size > 140 kg or BSA > 2.71 m2).

SourceLink

POLICY UPDATE CHANGES

Coverage Rationale updated.

Maximum Allowed Quantities by HCPCS Units updated.

Updated list of applicable HCPCS codes to reflect quarterly edits; added Q5162.

Bildyos and Bilprevda referenced/added to supporting information.

Archived previous policy version CSPA2026D0034AR.

100+Listed Drug Products

HCPCS & NDCCode Systems Provided

140 kg / 2.71 m2

95th percentile thresholds (weight/BSA)

100+Products Listed with NDC Limits in Part 2

ManyFrequency Rules Included

1Revision Date Entries (most recent)

1HCPCS Code Added (Q5162)

Coverage Rationale & Medical Necessity

Coverage Rationale / Medical Necessity Criteria

Coverage is determined by adherence to maximum dosage per administration and dosing frequency:

Proven when within maxima: Medication use within the maximum dosage and/or frequency based upon body surface area or patient weight or a set maximal dosage and/or frequency is considered proven when used according to labeled indications or supported by published clinical evidence (e.g., RCT systematic reviews, NCCN).
Unproven beyond maxima: Use beyond maximum dosages and/or frequency as defined in this policy is not supported by package labeling or published clinical evidence and is unproven.
Not medically necessary: Continued use of a medication or dosages beyond labeled indication or published clinical evidence is considered not medically necessary.

Per‑Product Maximum Dosage and HCPCS Unit Mapping

Per-Product Maximum Dosage / Allowed HCPCS Units

Each listed product has a maximum dosage per administration and a corresponding maximum allowed HCPCS billing unit quantity (unit-to-mg or unit-to-unit mapping as indicated). Coverage of doses should not exceed these limits except as noted under the body-size exception.

Actemra / Tocilizumab: tocilizumab (Actemra) - Max per admin: 800 mg; HCPCS: J3262; Maximum Allowed: 800 HCPCS units (1 mg per unit).
Tofidence / Tocilizumab-bavi: tocilizumab-bavi (Tofidence) - Max per admin: 800 mg; HCPCS: Q5133; Maximum Allowed: 800 HCPCS units (1 mg per unit).
Tyenne / Tocilizumab-aazg: tocilizumab-aazg (Tyenne) - Max per admin: 800 mg; HCPCS: Q5135; Maximum Allowed: 800 HCPCS units (1 mg per unit).

NDC Billing: Maximum Allowed Volumes and Vial Counts

NDC Billing Maximum Allowed Quantities

For NDC billing, maximum allowed volumes or vial counts are specified per NDC; absence of an NDC in the list does not imply it is not subject to the maxima.

Actemra NDCs: tocilizumab (Actemra) - How supplied: 20 mg/mL vials; NDCs: 50242-0135-01, 50242-0136-01, 50242-0137-01; Maximum Allowed: 40 mL.
Tofidence NDCs: tocilizumab-bavi (Tofidence) - How supplied: 20 mg/mL vials; NDCs: 64406-0022-01, 64406-0023-01, 64406-0024-01; Maximum Allowed: 40 mL.
Tyenne NDCs: tocilizumab-aazg (Tyenne) - How supplied: 20 mg/mL vials; NDCs: 65219-0590-04, 65219-0592-10, 65219-0594-20; Maximum Allowed: 40 mL.

Applicable HCPCS Codes and Updates

HCPCS maximum allowed (per-product)HCPCSCovered

J3262	tocilizumab (Actemra) - Max allowed 800 units (1 mg/unit)
Q5133	tocilizumab-bavi (Tofidence) - Max allowed 800 units (1 mg/unit)
Q5135	tocilizumab-aazg (Tyenne) - Max allowed 800 units (1 mg/unit)
J9035	bevacizumab (Avastin) - Max allowed 240 units (10 mg/unit)
Q5129	bevacizumab-adcd (Vegzelma) - Max allowed 240 units (10 mg/unit)
Q5107	bevacizumab-awwb (Mvasi) - Max allowed 240 units (10 mg/unit)
Q5118	bevacizumab-bvzr (Zirabev) - Max allowed 240 units (10 mg/unit)
Q5126	bevacizumab-maly (Alymsys) - Max allowed 240 units (10 mg/unit)
J9355	trastuzumab (Herceptin) - Max allowed 126 units (10 mg/unit)
Q5113	trastuzumab-pkrb (Herzuma) - Max allowed 126 units (10 mg/unit)

1–10 of 62

1/7

Applicable HCPCS updates noted in revisionHCPCS

Q5162	Added to replace miscellaneous/unspecified codes (per revision notes)
C9399	Replaced (removed) per revision notes
J3490	Replaced (removed) per revision notes
J3590	Replaced (removed) per revision notes
J9999	Replaced (removed) per revision notes

Provider Actions & Billing Requirements

Documentation Required

Adhere to per-product maximum dosage/frequency and document rationale

Ensure administered dose per administration and frequency do not exceed the policy's maximum allowed HCPCS units or NDC maximums. Document patient weight and/or BSA when doses approach limits and provide supporting rationale (e.g., clinical evidence or patient body size > 140 kg or BSA > 2.71 m2) if requesting doses beyond policy maxima.

Prior Authorization

Potential prior authorization for doses beyond policy maxima

Requests for dosing beyond the specified maximums should include supporting clinical evidence or documentation of body weight/BSA exceeding the 95th percentile thresholds (adult weight 140 kg or BSA 2.71 m2) to be considered; continued use beyond label or evidence is considered not medically necessary.

Background & Definitions

This policy compiles per-administration maximum dosages and corresponding billing unit limits (HCPCS units and NDC volumes/vial counts) for many physician-administered medications, and sets operational billing mappings (e.g., unit-to-mg or unit-to-unit) to guide claims reporting. The limits are evidence-based and the policy establishes an upper dose limit derived from the 95th percentile adult body weight (140 kg) and body surface area (2.71 m2) as described in the referenced anthropometric data. Operational allowances are noted so that maximum allowed units or vials may exceed the stated upper-level limit where clinically justified for larger patients (patient weight > 140 kg or BSA > 2.71 m2).

Definitions:

Maximum Allowed: Policy-specified maximum HCPCS units or NDC volume/vial counts permitted per administration for billing purposes, based on product-specific dosing and the policy's upper dose limits.

Threshold provenance: the policy’s upper limits reference the 95th percentile adult anthropometric values from Fryar et al. (2021) — 140 kg for adult body weight and 2.71 m2 for body surface area — which are the basis for the policy thresholds.

Policy thresholds and example HCPCS mapping

Adult body weight 95th percentile140 kg

Adult body surface area 95th percentile

Clinical Evidence Basis

Evidence summary and policy statement: The policy bases maximum per-administration dose limits on clinical evidence (product labeling, published clinical evidence such as well-designed randomized controlled trials and systematic reviews, and recognized guidance like NCCN) and applies an upper dose constraint using the 95th percentile adult weight/BSA (Fryar, 2021). Per the policy criteria, use within the stated maximum dosage/frequency supported by labeling or clinical evidence is considered proven; use beyond those maxima is unsupported or unproven and may be considered not medically necessary. Exceptions may be considered when justified by supporting clinical evidence or when a patient’s documented body size exceeds the 95th percentile thresholds (weight > 140 kg or BSA > 2.71 m2) — in such cases additional units/vials may be operationally allowed and should be documented for review.

Revision History

2026-05-01revisionLatest

Coverage Rationale updated.

2026-05-01revisionLatest

Maximum Allowed Quantities by HCPCS Units updated.

2026-05-01revisionLatest

Policy Summary

PayerUnitedHealthcare

PolicyMaximum Dosage and Frequency (for Pennsylvania Only) – Community Plan Medical Benefit Drug Policyopen_in_new

Policy CodePolicy CSPA2026D0034AS

Change TypeRevised HCPCS/NDC limits and coverage rationale

Effective DateMay 1, 2026

Next Review Date

SourceLink

On This Page

Avastin / Bevacizumab: bevacizumab (Avastin) - Max per admin: 15 mg/kg; HCPCS: J9035; Maximum Allowed: 240 HCPCS units (10 mg per unit).

Vegzelma / Bevacizumab-adcd: bevacizumab-adcd (Vegzelma) - Max per admin: 15 mg/kg; HCPCS: Q5129; Maximum Allowed: 240 HCPCS units (10 mg per unit).

Mvasi / Bevacizumab-awwb: bevacizumab-awwb (Mvasi) - Max per admin: 15 mg/kg; HCPCS: Q5107; Maximum Allowed: 240 HCPCS units (10 mg per unit).

Zirabev / Bevacizumab-bvzr: bevacizumab-bvzr (Zirabev) - Max per admin: 15 mg/kg; HCPCS: Q5118; Maximum Allowed: 240 HCPCS units (10 mg per unit).

Alymsys / Bevacizumab-maly: bevacizumab-maly (Alymsys) - Max per admin: 15 mg/kg; HCPCS: Q5126; Maximum Allowed: 240 HCPCS units (10 mg per unit).

Herceptin / Trastuzumab: trastuzumab (Herceptin) - Max per admin: 8 mg/kg; HCPCS: J9355; Maximum Allowed: 126 HCPCS units (10 mg per unit).

Herzuma / Trastuzumab-pkrb: trastuzumab-pkrb (Herzuma) - Max per admin: 8 mg/kg; HCPCS: Q5113; Maximum Allowed: 126 HCPCS units (10 mg per unit).

Kanjinti / Trastuzumab-anns: trastuzumab-anns (Kanjinti) - Max per admin: 8 mg/kg; HCPCS: Q5117; Maximum Allowed: 126 HCPCS units (10 mg per unit).

Ogivri / Trastuzumab-dkst: trastuzumab-dkst (Ogivri) - Max per admin: 8 mg/kg; HCPCS: Q5114; Maximum Allowed: 126 HCPCS units (10 mg per unit).

Ontruzant / Trastuzumab-dttb: trastuzumab-dttb (Ontruzant) - Max per admin: 8 mg/kg; HCPCS: Q5112; Maximum Allowed: 126 HCPCS units (10 mg per unit).

Trazimera / Trastuzumab-qyyp: trastuzumab-qyyp (Trazimera) - Max per admin: 8 mg/kg; HCPCS: Q5116; Maximum Allowed: 126 HCPCS units (10 mg per unit).

Stelara / Ustekinumab: ustekinumab (Stelara and variants) - Max per admin: 90 mg (and 520 mg formulation where applicable); HCPCS: J3357 (and J3358/Q-codes); Maximum Allowed: 90 HCPCS units (1 mg per unit) and 520 HCPCS units (1 mg per unit) as applicable per product/formulation.

Entyvio / Vedolizumab: vedolizumab (Entyvio) - Max per admin: 300 mg; HCPCS: J3380; Maximum Allowed: 300 HCPCS units (1 mg per unit).

Vutrisiran / Amvuttra: vutrisiran (Amvuttra) - Max per admin: 25 mg; HCPCS: J0225; Maximum Allowed: 25 HCPCS units (1 mg per unit).

Reclast / Zoledronic Acid: zoledronic acid (Reclast) - Max per admin: 5 mg; HCPCS: J3489; Maximum Allowed: 5 HCPCS units (1 mg per unit).

Aveed / Testosterone undecanoate: testosterone undecanoate (Aveed) - Max per admin: 750 mg; HCPCS: J3145; Maximum Allowed: 750 HCPCS units (1 mg per unit).

Botox / OnabotulinumtoxinA: onabotulinumtoxinA (Botox) - Max per admin: 600 units; HCPCS: J0585; Maximum Allowed: 600 HCPCS units (1 unit per HCPCS unit).

Cimzia / Certolizumab pegol: certolizumab pegol (Cimzia) - Max per admin: 400 mg; HCPCS: J0717; Maximum Allowed: 400 HCPCS units (1 mg per unit).

Cinqair / Reslizumab: reslizumab (Cinqair) - Max per admin: 3 mg/kg; HCPCS: J2786; Maximum Allowed: 500 HCPCS units (1 mg per unit).

Daxxify / DaxibotulinumtoxinA: daxibotulinumtoxinA (Daxxify) - Max per admin: 250 units; HCPCS: J0589; Maximum Allowed: 250 HCPCS units (1 unit per HCPCS unit).

Testosterone enanthate / cypionate: testosterone enanthate - Max per admin: 400 mg; HCPCS: J3121; Maximum Allowed: 400 HCPCS units (1 mg per unit). testosterone cypionate (Depo-Testosterone) - Max per admin: 400 mg; HCPCS: J1071; Maximum Allowed: 400 HCPCS units (1 mg per unit).

Dysport / AbobotulinumtoxinA: abobotulinumtoxinA (Dysport) - Max per admin: 1,500 units; HCPCS: J0586; Maximum Allowed: 300 HCPCS units (5 units per HCPCS unit).

Fasenra / Benralizumab: benralizumab (Fasenra) - Max per admin: 30 mg; HCPCS: J0517; Maximum Allowed: 30 HCPCS units (1 mg per unit).

Hemlibra / Emicizumab: emicizumab (Hemlibra) - Max per admin: 6 mg/kg; HCPCS: J7170; Maximum Allowed: 1,680 HCPCS units (0.5 mg per unit).

Rituxan Hycela / Rituximab + hyaluronidase: rituximab and hyaluronidase (Rituxan Hycela) - Max per admin: 1,600 mg; HCPCS: J9311; Maximum Allowed: 160 HCPCS units (10 mg per unit).

Rituximab and biosimilars: rituximab (Rituxan) and biosimilars (Ruxience, Truxima, Riabni, etc.) - Max per admin: 500 mg/m2 (also product-specific maxima listed); HCPCS: J9312, Q5119, Q5115, Q5123; Maximum Allowed: 150 HCPCS units (10 mg per unit).

Onpattro / Patisiran: patisiran (Onpattro) - Max per admin: 30 mg; HCPCS: J0222; Maximum Allowed: 300 HCPCS units (0.1 mg per unit).

Pegfilgrastim products: pegfilgrastim products (Neulasta and biosimilars) - Max per admin: 6 mg; HCPCS: J2506 and Q-codes; Maximum Allowed: 12 HCPCS units (0.5 mg per unit).

Rolvedon / Eflapegrastim: eflapegrastim (Rolvedon) - Max per admin: 13.2 mg; HCPCS: J1449; Maximum Allowed: 132 HCPCS units (0.1 mg per unit).

Krystexxa / Pegloticase: pegloticase (Krystexxa) - Max per admin: 8 mg; HCPCS: J2507; Maximum Allowed: 8 HCPCS units (1 mg per unit).

Niktimvo / Axatilimab: axatilimab (Niktimvo) - Max per admin: 35 mg; HCPCS: J9038; Maximum Allowed: 350 HCPCS units (0.1 mg per unit).

Nucala / Mepolizumab: mepolizumab (Nucala) - Max per admin: 300 mg; HCPCS: J2182; Maximum Allowed: 300 HCPCS units (1 mg per unit).

Ocrevus / Ocrelizumab: ocrelizumab (Ocrevus) - Max per admin: 600 mg; HCPCS: J2350; Maximum Allowed: 600 HCPCS units (1 mg per unit).

Omvoh / Mirikizumab: mirikizumab (Omvoh) - Max per admin: 900 mg; HCPCS: J2267; Maximum Allowed: 900 HCPCS units (1 mg per unit).

Opdivo / Nivolumab: nivolumab (Opdivo) - Max per admin: 480 mg; HCPCS: J9299; Maximum Allowed: 480 HCPCS units (1 mg per unit).

Orencia / Abatacept: abatacept (Orencia) - Max per admin: 1000 mg; HCPCS: J0129; Maximum Allowed: 100 HCPCS units (10 mg per unit).

PiaSky / Crovalimab: crovalimab (PiaSky) - Max per admin: 1500 mg; HCPCS: J1307; Maximum Allowed: 150 HCPCS units (10 mg per unit).

Keytruda / Pembrolizumab: pembrolizumab (Keytruda) - Max per admin: 400 mg; HCPCS: J9271; Maximum Allowed: 400 HCPCS units (1 mg per unit).

Libtayo / Cemiplimab: cemiplimab (Libtayo) - Max per admin: 350 mg; HCPCS: J9119; Maximum Allowed: 350 HCPCS units (1 mg per unit).

Tecentriq / Atezolizumab: atezolizumab (Tecentriq) - Max per admin: 1680 mg; HCPCS: J9022; Maximum Allowed: 168 HCPCS units (10 mg per unit).

Yervoy / Ipilimumab: ipilimumab (Yervoy) - Max per admin: 10 mg/kg; HCPCS: J9228; Maximum Allowed: 1400 HCPCS units (1 mg per unit).

Skyrizi / Risankizumab: risankizumab (Skyrizi) - Max per admin: 1200 mg; HCPCS: J2327; Maximum Allowed: 1200 HCPCS units (1 mg per unit).

Additional products: Numerous other products listed in the policy (e.g., avelumab, durvalumab, efgartigimod products, emicizumab, eptinezumab, faricimab, golimumab, guselkumab, inclisiran, incobotulinumtoxinA, infliximab and biosimilars, mepolizumab, mirikizumab, omalizumab, pegfilgrastim biosimilars, pegloticase, rituximab variants, vedolizumab, tocilizumab variants, denosumab variants including Bildyos and Bilprevda (Q5162), etc.) each have specific maximum per administration and HCPCS maximum allowed units as enumerated in the policy.

bevacizumab (Avastin) - 100 mg/4 mL vials NDCs: 50242-0060-01, 50242-0060-10; Max Allowed: 12 mL. Also 400 mg/16 mL vials NDCs: 50242-0061-01, 50242-0061-10; Max Allowed: 96 mL.

Vegzelma NDCs: bevacizumab-adcd (Vegzelma) - 100 mg/4 mL NDCs: 32228-0011-01, 32228-0011-02; Max: 12 mL; 400 mg/16 mL NDCs: 32228-0011-03, 32228-0011-04; Max: 96 mL.

Mvasi NDCs: bevacizumab-awwb (Mvasi) - 100 mg/4 mL NDC: 55513-0206-01; Max: 12 mL; 400 mg/16 mL NDC: 55513-0207-01; Max: 96 mL.

Zirabev NDCs: bevacizumab-bvzr (Zirabev) - 100 mg/4 mL NDC: 00069-0315-01; Max: 12 mL; 400 mg/16 mL NDC: 00069-0342-01; Max: 96 mL.

Alymsys NDCs: bevacizumab-maly (Alymsys) - 100 mg/4 mL NDCs: 70121-1754-01, 70121-1754-07; Max: 12 mL; 400 mg/16 mL NDCs: 70121-1755-01, 70121-1755-07; Max: 96 mL.

Aveed NDC: testosterone undecanoate (Aveed) - 750 mg/3 mL NDC: 67979-0511-43; Max Allowed: 3 mL.

Botox NDCs: onabotulinumtoxinA (Botox) - 100 unit vial NDC: 00023-1145-01; Max Allowed: 6 vials. 200 unit vial NDC: 00023-3921-02; Max Allowed: 3 vials.

Cimzia NDCs: certolizumab pegol (Cimzia) - NDCs: 50474-0700-62 (2x200mg kit) Max: 2 vials; 50474-0710-79 (2x200 mg/mL PFS) Max: 2 mL; 50474-0710-81 (6x200 mg/mL PFS) Max: 2 mL.

Cinqair NDC: reslizumab (Cinqair) - 100 mg/10 mL vial NDC: 59310-0610-31; Max Allowed: 50 mL.

Daxxify NDC: daxibotulinumtoxinA (Daxxify) - 100 unit vial NDC: 72960-112-01; Max Allowed: 3 vials.

Testosterone enanthate NDCs: testosterone enanthate - multiple NDCs listed; Maximum Allowed: 2 mL.

Depo-Testosterone NDCs: testosterone cypionate (Depo-Testosterone) - many NDCs listed; Maximum Allowed: 2 mL.

Dysport NDCs: abobotulinumtoxinA (Dysport) - multiple vial sizes and NDCs listed; Max Allowed varies by vial size (e.g., 3 vials for certain sizes, 5 vials for others) as specified in the policy.

Entyvio NDC: vedolizumab (Entyvio) - 300 mg vial NDC: 64764-0300-20; Max Allowed: 1 vial.

Fasenra NDCs: benralizumab (Fasenra) - 30 mg/mL PFS NDC: 00310-1830-30; Max Allowed: 1 mL; other Fasenra presentations and NDCs have specified max volumes.

Hemlibra NDCs: emicizumab (Hemlibra) - multiple presentations with NDCs and corresponding maximum allowed mL values (examples include NDC 50242-0920-01 Max 1 mL; 50242-0922-01 Max 0.7 mL; 50242-0923-01 Max 6 mL; 50242-0921-01 Max 0.4 mL).

Herceptin NDCs: trastuzumab (Herceptin) - 150 mg vial NDCs: 50242-0132-01, 50242-0132-10; Max Allowed: 8 vials.

Trastuzumab biosimilars NDCs: trastuzumab biosimilars (Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera) - NDCs and max allowed vial counts specified per product (examples: Herzuma 420 mg vial NDCs 63459-0305-47, 63459-0307-41 Max 3 vials; Kanjinti 420 mg vial NDC 55513-0132-01 Max 3 vials; Ogivri NDCs 67457-0847-44 etc. Max 3 vials).

Omvoh NDC: mirikizumab (Omvoh) - 300 mg/15 mL vial NDC: 00002-7575-01; Max Allowed: 3 vials.

Pegfilgrastim NDCs: pegfilgrastim products - NDCs and on-body injector presentations listed with Max Allowed = 0.6 mL for typical PFS presentations (e.g., Neulasta NDCs 55513-0190-01 and 55513-0192-01 Max 0.6 mL).

Rituxan NDCs: rituximab (Rituxan) - 100 mg/10 mL vial NDCs: 50242-0051-10, 50242-0051-21; Max Allowed: 40 mL. Rituxan 500 mg/50 mL vial NDC: 50242-0053-06; Max Allowed: 150 mL. Ruxience, Truxima, Riabni NDCs and corresponding max mL values listed similarly.

Rituxan Hycela NDCs: Rituxan Hycela (rituximab and hyaluronidase) - NDCs: 50242-0108-01 (1,400-23,400 mg/11.7 mL) and 50242-0109-01 (1,600-26,800 mg/13.4 mL); Maximum Allowed: 1 vial each.

Vyvgart Hytrulo NDC: Vyvgart Hytrulo - NDC: 73475-3102-03; How supplied: 1,008 mg + hyaluronidase 11,200 units/5.6 mL; Maximum Allowed: 5.6 mL.

Reclast NDCs: Reclast (zoledronic acid) - multiple NDCs listed for 4 mg/5 mL vials and 4 mg/100 mL infusions; Max Allowed: 5 mL for 4 mg/5 mL vials and 100 mL for infusion presentations as specified.

Additional NDC mappings: Many additional NDC-to-maximum allowed volume/vial mappings are listed in the policy part; absence of a given NDC in this extract does not indicate it is not subject to the maxima.

NDC maximum allowed (per-product)NDCCovered

50242-0135-01	tocilizumab Actemra NDC - Max 40 mL
50242-0136-01	tocilizumab Actemra NDC - Max 40 mL
50242-0137-01	tocilizumab Actemra NDC - Max 40 mL
64406-0022-01	Tofidence NDC - Max 40 mL
64406-0023-01	Tofidence NDC - Max 40 mL
64406-0024-01	Tofidence NDC - Max 40 mL
50242-0060-01	Avastin 100 mg/4 mL NDC - Max 12 mL
50242-0060-10	Avastin 100 mg/4 mL NDC - Max 12 mL
50242-0061-01	Avastin 400 mg/16 mL NDC - Max 96 mL
50242-0061-10	Avastin 400 mg/16 mL NDC - Max 96 mL

1–10 of 166

1/17

Billing Rule

Use specified HCPCS codes and units per policy

Bill using the listed HCPCS code and report units consistent with the policy's unit mapping for each product (e.g., bevacizumab uses 10 mg per HCPCS unit; many products list 1 mg per HCPCS unit). For NDC billing, report the NDC and quantity consistent with the listed maximum allowed mL or vial counts.

Affected code examples: bevacizumab (J9035 / Q5129 / Q5107 / Q5118 / Q5126) = 240 HCPCS units (10 mg per unit) -> mapping = 10 mg per HCPCS unit
Many other products list 1 mg per HCPCS unit (e.g., tocilizumab J3262 = 800 HCPCS units (1 mg per unit))

Denial Risk

Denial risk for doses beyond maxima without justification

Claims for medication doses or frequencies exceeding the policy maximums may be denied as unproven or not medically necessary unless justified by labeling, clinical evidence, or documented patient body size exceeding the 95th percentile (weight > 140 kg or BSA > 2.71 m2).

Billing Rule

Adhere to NDC-level maximum allowed quantities

When billing NDCs listed, do not exceed the specified Maximum Allowed volume (mL) or vial/unit counts for each NDC/product presentation; claims may be limited or denied if billed quantities exceed these NDC-level maxima.

Billing Rule

Use specified frequency limits for administration

Adhere to the maximum administration frequencies listed for each medication/indication (examples include Neulasta and many ophthalmic and oncology agents); billing for administrations more frequently than listed may be subject to review or denial.

Example: Neulasta (pegfilgrastim) – maximum frequency: once every 2 weeks (J2506 / 55513-0190-01 listed).
Example: Eylea (aflibercept) – initial monthly dosing then every 8 weeks thereafter.

Documentation Required

Refer to federal/state/contractual benefit requirements

When deciding coverage, reference applicable federal, state, or contractual benefit requirements as they may differ from this UnitedHealthcare policy; those requirements govern in the event of conflict.

Documentation Required

Use InterQual and clinical judgment

UnitedHealthcare may use third-party tools (e.g., InterQual) to assist in administering benefits; providers should apply independent professional medical judgment alongside the policy when making clinical decisions.

Billing Rule

HCPCS code changes effective per revision

Providers must bill using updated HCPCS codes reflecting the 05/01/2026 revision: unspecified/miscellaneous codes (C9399, J3490, J3590, J9999) were replaced with Q5162 where noted. Use the listed HCPCS code set for billing.

Q5162
C9399
J3490
J3590
J9999

Example HCPCS-to-strength mappinge.g., bevacizumab = 10 mg per HCPCS unit (J9035 = 240 units for 2400 mg)

Updated list of applicable HCPCS codes to reflect quarterly edits; added Q5162. Replaced C9399, J3490, and J3590 with Q5162; replaced C9399 and J9999 with Q5162 for specified products Bildyos and Bilprevda.

2026-05-01additionLatest

Bildyos and Bilprevda referenced/added to supporting information.

2026-05-01archivalLatest

Archived previous policy version CSPA2026D0034AR.

2026-05-01publicationLatest

Policy effective date set to May 1, 2026 (most recent revision).

note

Prior policy version CSPA2026D0034AR exists (archived).