ModifiedUnitedHealthcarePolicy 2025D0034AR

Maximum Dosage and Frequency

Defines upper dose limits (per administration and frequency) and maximum HCPCS unit allowances for specified medications administered by a medical professional; applies to UnitedHealthcare Commercial Medical Benefit claims and providers administering these drugs.

Policy Summary

PayerUnitedHealthcare

PolicyMaximum Dosage and Frequency

Policy CodePolicy 2025D0034AR

Change TypeAdded HCPCS/NDC maximums & products

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionWhen billing by NDC or HCPCS, use the exact listed code and adhere to the policy's maximum allowed quantities and frequencies; prior authorization may be required for requests that exceed those limits.

SourceLink

POLICY UPDATE CHANGES

Added reference link to the Medical Benefit Drug Policy titled Niktimvo™ (Axatilimab-Csfr) Coverage Rationale.

Revised list of applicable drug products; added multiple products including aflibercept-ayyh (Pavblu™), axatilimab-csfr (Niktimvo™), tocilizumab-aazg (Tyenne®), tocilizumab-bavi (Tofidence™), and several ustekinumab biosimilars.

Added maximum allowed quantities for multiple products by HCPCS units (e.g., Niktimvo J9038; Otulfi Q9999; Pyzchiva Q9996/Q9997; Selarsdi Q9998; Tofidence Q5133; Tyenne Q5135; Wezlana Q5137/Q5138).

Added maximum allowed quantities for specific NDCs for Niktimvo, Otulfi, Pyzchiva, Selarsdi, Tofidence, Tyenne, and Wezlana.

Added maximum allowed frequencies for Niktimvo, Otulfi, and Pavblu (aflibercept-ayyh).

Added maximum allowed quantities/frequencies for multiple products including Niktimvo (axatilimab-csfr), Otulfi (ustekinumab-aauz), Pyzchiva (ustekinumab-ttwe), Selarsdi (ustekinumab-aekn), Tofidence (tocilizumab-bavi), Tyenne (tocilizumab-aazg), Wezlana (ustekinumab-auub), Pavblu (aflibercept-ayyh), and others.

Added HCPCS codes J9038, Q5133, Q5135, Q5137, Q5138, Q5147, Q9996, Q9997, Q9998, and Q9999 to Applicable Codes.

Added multiple NDCs for listed products (examples include 50881-0012-10, 50881-0023-11, 50881-0034-12, 51759-0505-32, 61314-0651-01, 64406-0022-01, 65219-0590-04, 65219-0824-01, 84612-0055-01, and others).

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

32document length (pages)

~90+listed drug products

HCPCS capscoding-level dose caps

12intravitreal max doses/yr/eye

~170unique product/packaging codes

Coverage Criteria

inv-01: Within-label dosing

Covered when ALL of the following are met

Within labeled or evidence-supported dosing: Use within the maximum dosage and/or frequency based upon body surface area, patient weight, or a set maximal dosage is proven when used according to labeled indications or supported by published clinical evidence.

Supported by FDA prescribing information or high-quality published evidence (see product-specific HCPCS/NDC maximums).

inv-02: Not medically necessary (doses beyond maximum)

Considered not medically necessary when ANY of the following apply

Beyond labeled or evidence-supported dosing: Continued use of a medication or dosing beyond labeled indications or published clinical evidence is considered not medically necessary.

Upper dose limits are derived from evidence and the 95th percentile adult weight (140 kg) and BSA (2.71 m2); doses above these limits lack supporting evidence and may be denied.

inv-03: Maximum frequency-based coverage criteria

Coverage follows FDA-approved dosing or, where no FDA dosing exists for the indication, available clinical evidence.

General maximum frequency rule: Medication administration must not exceed the listed Maximum Frequency derived from FDA labeling or clinical evidence for the specified diagnosis/indication.as listed per drug/indication

Examples and drug‑specific maximum frequencies are provided in the policy (see intravitreal agents, tocilizumab, pegfilgrastim, etc.).

inv-04: Maximum Allowed Frequencies (per drug and indication)

Covered when dosing does not exceed the listed maximum frequency for the specified medication and indication

Per-drug maximum frequency compliance: Each listed medication must be administered no more frequently than its specified Maximum Frequency for the indicated diagnosis (examples include intravitreal agents: maximum of 12 doses per eye per year; Actemra for GCA once every 4 weeks; pegfilgrastim products once every 2 weeks; Pavblu/aflibercept initial monthly dosing then q8 weeks).see per-drug entries in policy

Refer to the policy's Maximum Allowed Frequencies section for the exact interval for each drug/indication.

inv-05: Covered when ALL of the following are met

Coverage of listed medications is supported when dosing is within product-specific maximums based on weight or body surface area and consistent with FDA labeling or peer-reviewed evidence.

Dose within product-specific weight/BSA limits: Dose does not exceed the product-specific maximum dosage based on body weight or body surface area as defined in FDA prescribing information or peer-reviewed compendia.see product-specific thresholds; adult upper reference: weight 140 kg, BSA 2.71 m2

This policy establishes an upper dose limit using the 95th percentile adult weight (140 kg) and BSA (2.71 m2); individual patient factors and product labeling may supersede. Doses exceeding these limits are not supported by evidence.

Dosing that exceeds package labeling or published clinical evidence is not supported and is considered not medically necessary. The policy defines upper dose limits using product-specific maximums and, where applicable, body weight or body surface area limits. Continued use beyond labeled indications or high-quality published evidence (for example, randomized controlled trials or guideline-supported dosing) may be denied.

The lists of maximum frequencies and products in this policy are illustrative and may change. Absence of a medication from the listed entries is not authorization to exceed standard dosing limits; providers must follow FDA labeling or the clinical evidence cited for the indication.

Procedure, HCPCS, Q- and NDC codes included in this policy are provided for reference only. Listing a code does not imply the service is covered; actual coverage is determined by the member’s benefit plan and applicable law and may require additional policy review or authorization.

Use of medications beyond established maximum dosages based on body weight or body surface area is not supported by the clinical evidence summarized in this policy. The policy derives an adult upper-cap using the 95th percentile adult weight (140 kg) and BSA (2.71 m2) and does not endorse routine dosing above product-specific maximums without strong supporting evidence.

Administration of medications at dosages or frequencies that exceed FDA-approved labeling or published clinical evidence is considered not medically necessary. Coverage follows authorized dosing intervals and maximum frequencies derived from product labeling or available evidence for the indicated diagnosis.

Administration in excess of a medication’s stated Maximum Frequency may not be covered. For example, many intravitreal agents have a maximum of 12 doses per year per eye; dosing beyond such stated annual maxima would not align with the policy without documented justification.

Requests for dosing that exceed product-specific maximums calculated by body weight or body surface area are considered not medically necessary because evidence does not demonstrate additional benefit and higher doses increase the risk of adverse events. The policy’s upper dose threshold references the 95th percentile adult weight (140 kg) and BSA (2.71 m2) when deriving adult caps.

Coding and Applicable Codes

Example: Tocilizumab productsHCPCSCovered

J3262	Actemra (tocilizumab) - 1 mg per unit
Q5133	Tofidence (tocilizumab-bavi) - 1 mg per unit
Q5135	Tyenne (tocilizumab-aazg) - 1 mg per unit

Bevacizumab and testosterone examplesHCPCSCovered

J9035	Avastin (bevacizumab) - 10 mg per unit
Q5129	Vegzelma (bevacizumab-adcd) - 10 mg per unit
Q5107	Mvasi (bevacizumab-awwb) - 10 mg per unit
Q5118	Zirabev (bevacizumab-bvzr) - 10 mg per unit
Q5126	Alymsys (bevacizumab-maly) - 10 mg per unit
J3145	Aveed (testosterone undecanoate) - 1 mg per unit

Maximum Allowed Quantities by HCPCS Units (selected entries)HCPCSCovered

J0585	Botox (onabotulinumtoxinA) - 1 unit per HCPCS unit
J0717	Cimzia (certolizumab pegol) - 1 mg per unit
J2786	Cinqair (reslizumab) - 1 mg per unit
J0589	Daxxify (daxibotulinumtoxinA-lanm) - 1 unit per HCPCS unit
J3121	Testosterone enanthate - 1 mg per unit (N/A)
J1071	Depo-Testosterone (testosterone cypionate) - 1 mg per unit
J0586	Dysport (abobotulinumtoxinA) - 5 units per HCPCS unit
J3380	Entyvio (vedolizumab) - 1 mg per unit
J0517	Fasenra (benralizumab) - 1 mg per unit
J7170	Hemlibra (emicizumab-kxwh) - 0.5 mg per unit

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HCPCS codes (partial list from excerpt)HCPCS

J1307	PiaSky (crovalimab-akkz) HCPCS code
J3489	Reclast / Zoledronic acid HCPCS code
Q5121	Avsola (infliximab-axxq) HCPCS code
Q5103	Inflectra (infliximab-dyyb) HCPCS code
J1745	Remicade (infliximab) HCPCS code

HCPCS codes (continued)HCPCS

J1304	Qalsody (tofersen) HCPCS code
J1301	Radicava (edaravone) HCPCS code
J9312	Rituxan (rituximab) HCPCS code
Q5119	Ruxience (rituximab-pvvr) HCPCS code
Q5115	Truxima (rituximab-abbs) HCPCS code
Q5123	Riabni (rituximab-arrx) HCPCS code
J9311	Rituxan Hycela HCPCS code
J9333	Rystiggo (rozanolixizumab-noli) HCPCS code
J1602	Simponi Aria (golimumab) HCPCS code
J1299	Soliris (eculizumab) HCPCS code

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NDCs (partial list from excerpt)NDC

50242-0135-01	Actemra NDC
50242-0060-01	Avastin 100 mg/4mL vial NDC
55513-0206-01	Mvasi NDC
00023-1145-01	Botox 100 unit vial NDC
72960-112-01	Daxxify NDC
50242-0132-01	Herceptin 150 mg vial NDC

NDC entries (sample from chunk 36)NDC

50242-0923-01	Hemlibra, Maximum Allowed = 6 mL (Hemlibra 60 mg/0.4 mL)
50242-0921-01	Hemlibra related NDC mapping (per chunk)
50242-0132-01	Herceptin 150 mg vial, Maximum Allowed = 8 vials

NDC entries (sample from chunk 37)NDC

00002-7575-01	Omvoh 300 mg/15 mL vial, Maximum Allowed = 3 vials
00006-5033-02	Ontruzant 150 mg vial, Maximum Allowed = 3 vials
00069-0305-01	Trazimera 420 mg vial, Maximum Allowed = 3 vials

NDC entries (sample from chunks 38-41)NDC

00078-0734-61	Ilaris 150 mg/mL vials, Maximum Allowed = 2 mL
00078-1000-60	Leqvio 284 mg/1.5 mL PFS, Maximum Allowed = 1.5 mL
10454-0710-10	Myobloc 2,500 Units/0.5 mL vial, Maximum Allowed = 12 vials
55513-0190-01	Neulasta 6 mg/0.6 mL PFS, Maximum Allowed = 0.6 mL
50881-0034-12	Niktimvo 9 mg/0.18 mL vials, Maximum Allowed = 4 vials

NDC entries (sample from chunks 42-43)NDC

50242-0150-01	Ocrevus 300 mg/10 mL vial, Maximum Allowed = 20 mL
00003-3774-12	Opdivo 100 mg/10 mL vials, Maximum Allowed = 40 mL
71336-1000-01	Onpattro 10 mg/5 mL vials, Maximum Allowed = 15 mL
71336-1003-01	Amvuttra 25 mg/0.5 mL PFS, Maximum Allowed = 0.5 mL

NDC entries (sample from chunks 44-46)NDC

00003-2187-10	Orencia 250 mg vials, Maximum Allowed = 4 vials
57894-0030-01	crovalimab-akkz 100 mg vials, Maximum Allowed = 14 vials
55513-0670-01	Avsola (infliximab-axxq) 100 mg vials, Maximum Allowed = 14 vials
50242-0051-10	Rituxan 100 mg/10 mL vials, Maximum Allowed = 40 mL
50242-0053-06	Rituxan 500 mg/50 mL vials, Maximum Allowed = 150 mL

NDC entries (sample from chunks 47-51)NDC

50474-0980-79	Rystiggo 280 mg/2 mL vials, Maximum Allowed = 6 mL
25682-0001-01	Soliris 300 mg/30 mL vials, Maximum Allowed = 120 mL
00597-0035-10	Spevigo 450 mg/7.5 mL vials, Maximum Allowed = 15 mL
61314-0651-01	Pyzchiva 45 mg/0.5 mL PFS, Maximum Allowed = 0.5 mL
57894-0060-03	Stelara 45 mg/0.5 mL PFS, Maximum Allowed = 0.5 mL

NDC entries (sample from chunks 52-55)NDC

55513-0123-01	Tezspire 210 mg/1.91 mL pre-filled pen, Maximum Allowed = 1.91 mL
67457-0390-54	Reclast various NDCs, Maximum Allowed = 5 mL (or up to 100 mL for other presentations)
50242-0214-01	Xolair 150 mg vials, Maximum Allowed = 4 vials
73475-3041-05	Vyvgart 400 mg/20 mL vials, Maximum Allowed = 60 mL

NDC-specific Maximum Allowed quantities (partial list)NDCCovered

50242-0214-55	Xolair (omalizumab) 150 mg/mL autoinjector — Maximum Allowed = 0.5 mL
50242-0215-55	Xolair (omalizumab) 300 mg/2 mL autoinjector — Maximum Allowed = 4 mL
50242-0227-55	Xolair (omalizumab) 300 mg/2 mL autoinjector — Maximum Allowed = 4 mL
55513-0710-01	Prolia (denosumab) 60 mg/1 mL PFS — Maximum Allowed = 1 mL
55513-0730-01	Xgeva (denosumab) 120 mg/1.7 mL vials — Maximum Allowed = 1.7 mL
64406-0109-01	Qalsody (tofersen) 100 mg/15 mL vials — Maximum Allowed = 15 mL
70510-2171-01	Radicava (edaravone) 30 mg/100 mL bags — Maximum Allowed = 200 mL
70510-2171-02	Radicava (edaravone) 30 mg/100 mL bags — Maximum Allowed = 200 mL
00409-4215-01	Reclast (zoledronic acid) 4 mg/5 mL vials — Maximum Allowed = 5 mL

Additional NDC-specific Maximum Allowed quantities (partial list)NDCCovered

67457-0390-54	Reclast (zoledronic acid) 4 mg/5 mL — Maximum Allowed = 5 mL
70860-0210-51	Reclast (zoledronic acid) 4 mg/100 mL vials — Maximum Allowed = 100 mL
44087-3535-01	Bavencio (avelumab) 200 mg/10 mL vials — Maximum Allowed = 40 mL
00310-4500-12	Imfinzi (durvalumab) 120 mg/2.4 mL vials — Maximum Allowed = 9.6 mL
00310-4611-50	Imfinzi (durvalumab) 500 mg/10 mL vials — Maximum Allowed = 30 mL
00006-3029-01	Keytruda (pembrolizumab) 50 mg vials — Maximum Allowed = 8 vials
00006-3029-02	Keytruda (pembrolizumab) 50 mg vials — Maximum Allowed = 8 vials
00006-3026-01	Keytruda (pembrolizumab) 100 mg/4 mL vials — Maximum Allowed = 16 mL
00006-3026-02	Keytruda (pembrolizumab) 100 mg/4 mL vials — Maximum Allowed = 16 mL
61755-0008-01	Libtayo (cemiplimab-rwlc) 350 mg/7 mL vials — Maximum Allowed = 7 mL

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Applicable HCPCS/J/Q/S codesmixed

J0129	Injection, abatacept, 10 mg
J0177	Injection, aflibercept HD, 1 mg
J0178	Injection, aflibercept, 1 mg
J0179	Injection, brolucizumab-dbll, 1 mg
J0222	Injection, patisiran, 0.1 mg
J0225	Injection, vutrisiran, 1 mg
J0517	Injection, benralizumab, 1 mg
J0585	Injection, onabotulinumtoxinA, 1 unit
J0586	Injection, abobotulinumtoxinA, 5 units
J0587	Injection, rimabotulinumtoxinB, 100 units

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Product/NDC or labeler codesNDC

50242-0135-01	Actemra 20 mg/mL vial
50242-0136-01	Actemra 200 mg/10 mL vial
50242-0137-01	Actemra 400 mg/20 mL vial
70121-1754-01	Alymsys 100mg/4mL vial
70121-1754-07	Alymsys 100mg/4mL vial
70121-1755-01	Alymsys 400mg/16mL vial
70121-1755-07	Alymsys 400mg/16mL vial
71336-1003-01	Amvuttra 25 mg/0.5 mL PFS
50242-0060-01	Avastin 100 mg/4 mL vial
50242-0060-10	Avastin 100 mg/4 mL vial

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Applicable Q/S Codes (partial)HCPCS

Q5137	Injection, tocilizumab-aazg (tyenne), biosimilar, 1 mg
Q5138	Injection, ustekinumab-auub (wezlana), biosimilar, subcutaneous, 1 mg
Q5147	Injection, ustekinumab-auub (wezlana), biosimilar, intravenous, 1 mg
Q9996	Injection, aflibercept-ayyh (Pavblu), biosimilar, 0.1 mg
Q9997	Injection, ustekinumab-ttwe (pyzchiva), subcutaneous, 1 mg
Q9998	Injection, ustekinumab-ttwe (pyzchiva), intravenous, 1 mg
Q9999	Injection, ustekinumab-aekn (selarsdi), 1 mg
S0189	Testosterone pellet, 75 mg

Applicable NDC/packaging codes (sample)NDC

50242-0135-01	Actemra 20 mg/mL vial
50242-0136-01	Actemra 200 mg/10 mL vial
50242-0137-01	Actemra 400 mg/20 mL vial
70121-1754-01	Alymsys 100mg/4mL vial
70121-1755-01	Alymsys 400mg/16mL vial
71336-1003-01	Amvuttra 25 mg/0.5 mL PFS
50242-0060-01	Avastin 100 mg/4 mL vial
50242-0061-01	Avastin 400 mg/16 mL vial
67979-0511-43	Aveed 750 mg/3 mL vial
55513-0670-01	Avsola 100 mg vial

Additional applicable NDC/packaging codes (partial)NDC

50474-0700-62	Cimzia 2 x 200mg kit
50474-0710-79	Cimzia 2 x 200mg/ml prefilled syringe (PFS) kit
00310-1730-30	Fasenra 30mg/mL PFS
00310-1745-01	Fasenra 10 mg/0.5 mL PFS
50242-0132-01	Herceptin 150 mg vial
00069-0809-01	Inflectra 100 mg vial
55513-0141-01	Kanjinti 150 mg vial
00006-3029-01	Keytruda 50 mg vial
00006-3026-02	Keytruda 100 mg/4 mL vial
75987-0080-10	Krystexxa 8mg/mL vial

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HCPCS codes with added maximum allowed quantitiesHCPCSCovered

J9038	Niktimvo (axatilimab-csfr) — HCPCS code referenced for maximum allowed quantities
Q9999	Otulfi (ustekinumab-aauz) — HCPCS code referenced for maximum allowed quantities
Q9996	Pyzchiva (ustekinumab-ttwe) — HCPCS code referenced for maximum allowed quantities
Q9997	Pyzchiva (ustekinumab-ttwe) — HCPCS code referenced for maximum allowed quantities
Q9998	Selarsdi (ustekinumab-aekn) — HCPCS code referenced for maximum allowed quantities
Q5133	Tofidence (tocilizumab-bavi) — HCPCS code referenced for maximum allowed quantities
Q5135	Tyenne (tocilizumab-aazg) — HCPCS code referenced for maximum allowed quantities
Q5137	Wezlana (ustekinumab-auub) — HCPCS code referenced for maximum allowed quantities
Q5138	Wezlana (ustekinumab-auub) — HCPCS code referenced for maximum allowed quantities

NDCs with added maximum allowed quantitiesNDCCovered

50881-0012-10	Niktimvo NDC included in maximum allowed quantities list
50881-0023-11	Niktimvo NDC included in maximum allowed quantities list
50881-0034-12	Niktimvo NDC included in maximum allowed quantities list
65219-0824-01	Otulfi NDC included in maximum allowed quantities list
65219-0826-26	Otulfi NDC included in maximum allowed quantities list
65219-0828-05	Otulfi NDC included in maximum allowed quantities list
61314-0651-01	Pyzchiva NDC included in maximum allowed quantities list
61314-0652-01	Pyzchiva NDC included in maximum allowed quantities list
61314-0654-94	Pyzchiva NDC included in maximum allowed quantities list
51759-0505-32	Selarsdi NDC included in maximum allowed quantities list

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Added HCPCS CodesHCPCS

J9038
Q5133
Q5135
Q5137
Q5138
Q5147
Q9996
Q9997
Q9998
Q9999

Added NDCsNDC

50881-0012-10
50881-0023-11
50881-0034-12
51759-0505-32
51759-0607-32
51759-0708-13
61314-0651-01
61314-0652-01
61314-0654-94
64406-0022-01

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Adult body weight/BSA

Adult body weight (95th percentile)>= 140 kg

Body surface area (95th percentile)BSA >= 2.71 m^2

Use in upper-dose derivation

Provider Actions and Billing Guidance

Billing Rule

Billing and Prior Authorization — HCPCS

Use the HCPCS maximums listed in this policy when submitting prior authorization requests and when billing/filing claims. When a product is billed using HCPCS, the HCPCS-specific maximum allowed units per administration in the "Maximum Allowed Quantities by HCPCS Units" tables should be applied for PA review and claims adjudication.

Apply HCPCS unit maximums from the policy in PA and claims submission.
If billed quantity exceeds the HCPCS maximum units listed, the request may require prior authorization review and may be subject to payment adjustment or denial.

Billing Rule

Billing and Prior Authorization — NDC

When billing under NDC/labeler-package codes, use the NDCs and NDC-specific maximum volumes/units listed in the policy. NDC-level maximums are documented and may trigger prior authorization or payment adjustment if the billed NDC or quantity exceeds the listed maximums.

Quantity Limits and Per-Administration Maximums

Actemra (tocilizumab) — 800 mg

Actemra (tocilizumab) maximum800 mg per administration (Maximum Allowed = 800 HCPCS units; J3262)

HCPCS unit definitionActemra entry lists 1 mg per HCPCS unit for the product in the table

Policy locationMaximum Allowed Quantities by HCPCS Units section (see policy for code J3262)

Avastin (bevacizumab) — 15 mg/kg

Avastin (bevacizumab) maximum15 mg/kg per administration (Maximum Allowed = 240 HCPCS units at 10 mg/unit; J9035)

Intravitreal ophthalmic useOphthalmic indications list typical intravitreal dose 1.25 mg near-monthly with maximum 12 doses/year/eye

Initial Therapy Criteria

inv-85: Initial dosing examples

Initial dosing/loading schedules where specified

Lucentis (ranibizumab) initial dosing: Recommended initial dosing per labeling: 0.3 mg (DME) or 0.5 mg (nAMD/RVO) intravitreal once monthly for up to 3 months, with maximum of 12 doses per year per eye.0.3–0.5 mg monthly; 12 doses/year per eye

Indication-specific mg dosing and schedules are in the policy; follow labeled loading regimens.

Pavblu (aflibercept-ayyh) initial dosing: Recommended initial regimen: 2 mg every 4 weeks for the initial period (varies by indication) followed by 2 mg every 8 weeks for maintenance; maximum of 12 doses per year per eye for ophthalmic indications.2 mg q4wk initial then q8wk maintenance; 12 doses/year per eye

See Pavblu entry for indication‑specific initiation duration (e.g., first 12 or 20 weeks).

Continuation Therapy Criteria

inv-87: Maintenance dosing examples

Examples of maintenance/continuation dosing

Vabysmo maintenance: After initial monthly dosing for 4 doses, continue with one of the specified extended regimens; most patients require dosing every 8 weeks thereafter.per regimen; typically q8wk

See Vabysmo entry for regimen options and monitoring.

Ranibizumab/Lucentis maintenance: After initial monthly dosing, treatment may be reduced per labeled guidance; maximum of 12 doses per eye per year applies to maintenance as well.12 doses/year per eye

Adjust intervals per clinical response and labeled guidance.

inv-88: Continuation therapy

Continuation allowed when prior dosing met criteria and remains within approved maximums

Step Therapy

Step	Requirement / Notes
1
No explicit step‑therapy sequences are specified in this policy excerpt. Coverage and authorization are based on adherence to product‑specific dosing, maximum per‑administration quantities, and maximum allowed frequencies (for example, many intravitreal agents have a maximum of 12 doses per year per eye). Refer to individual product entries and coverage rationales for any product‑specific step‑therapy rules.

Step

Requirement / Notes

No explicit step‑therapy sequences are specified in this policy excerpt. Coverage and authorization are based on adherence to product‑specific dosing, maximum per‑administration quantities, and maximum allowed frequencies (for example, many intravitreal agents have a maximum of 12 doses per year per eye). Refer to individual product entries and coverage rationales for any product‑specific step‑therapy rules.

Step	Editing priority / Notes
1
No specific step edits are included in this excerpt. When implementing edits, dosing and quantity limits take precedence — requests should be evaluated against product‑specific maximum per‑administration doses and maximum allowed frequencies (policy uses 95th percentile adult weight/BSA to derive upper dose limits). Exceptions or alternative sequences must be supported by product labeling or published clinical evidence.

Step

Editing priority / Notes

No specific step edits are included in this excerpt. When implementing edits, dosing and quantity limits take precedence — requests should be evaluated against product‑specific maximum per‑administration doses and maximum allowed frequencies (policy uses 95th percentile adult weight/BSA to derive upper dose limits). Exceptions or alternative sequences must be supported by product labeling or published clinical evidence.

Site of Care

Note

No site‑of‑care restrictions specified in these chunks

The excerpt does not specify site‑of‑care restrictions; administration is listed under the medical benefit and is typically performed in infusion centers, offices, or hospital outpatient settings per standard practice.

No site‑of‑care restrictions are provided in this excerpt; follow local payer/site policies if present.
Ensure the billing place-of-service aligns with the product's standard administration setting.

Note

No explicit site‑of‑care restrictions listed; administration assumed in clinical settings

No explicit site‑of‑care restrictions are listed in the provided sections; product vial and J-code listings assume administration in appropriate clinical settings such as infusion centers, physician offices, or hospital outpatient departments.

Providers should bill using the appropriate place of service but the policy excerpt does not mandate a specific site of care.
Check member benefit documents for any site‑of‑care limitations not reflected in this excerpt.

Biosimilars and Originator Products

Billing Rule

Bevacizumab (Avastin) — biosimilar codes listed alongside reference products; product-specific maximum frequencies per indication

Biosimilar HCPCS/Q-codes are listed alongside reference biologic products (e.g., Avastin and its biosimilars Mvasi, Vegzelma, Zirabev) and product-specific maximum frequencies are provided by indication — apply the per‑product frequency limits when authorizing or billing.

Example: Avastin and biosimilars have a recommended near‑monthly intravitreal dosing with a maximum of 12 doses per year per eye for ophthalmic indications.
Biosimilar codes (Q-codes) should be used when billing the corresponding biosimilar product packaging.

Billing Rule

Originator biologics where applicable — multiple biosimilars and originator products listed with packaging codes; interchangeability not specified

Originator biologics and their biosimilars are listed with specific packaging codes (HCPCS and NDC); the policy does not specify a selection preference or interchangeability — use the exact product code/packaging when submitting PA or claims.

Examples include Remicade and infliximab biosimilars (Avsola, Inflectra, Renflexis) and trastuzumab originator and biosimilars (Herceptin, Ogivri, Ontruzant, etc.).
Selection of agent and billing should match the administered product's HCPCS/Q-code or NDC; interchangeability is not addressed in this excerpt.

Background

This policy sets upper dose limits based on FDA-approved product labeling and published clinical evidence. When an adult upper cap is needed, the policy uses the 95th percentile for adult body weight (140 kg) and body surface area (2.71 m2) as the basis for determining maximum allowable dosing; product-specific maximums and frequency limits from labeling or evidence remain authoritative.

Definitions

Upper dose limit methodology

Methodology summaryUpper dose limit methodology uses the 95th percentile for adult body weight (140 kg) and BSA (2.71 m^2)

RationaleDerived from clinical evidence and population percentiles (Fryar, 2021) to define adult upper caps when product-specific maxima absent

ApplicationProduct-specific maximums remain authoritative; the 95th percentile values are used to derive general adult caps

Maximum Frequency — definition

Definition of Maximum FrequencyThe Maximum Frequency is based on FDA prescribing information or, where no FDA dosing exists for the indication, available clinical evidence

ExamplesIntravitreal agents commonly limited to 12 doses/year per eye; other products have label-derived intervals (e.g., Actemra every 4 weeks)

Revision History

2025-07-01policy_revisionLatest

Revised list of applicable drug products and added multiple products including Pavblu (aflibercept-ayyh), Niktimvo (axatilimab-csfr), Tyenne (tocilizumab-aazg), Tofidence (tocilizumab-bavi), Otulfi (ustekinumab-aauz), Selarsdi (ustekinumab-aekn), Wezlana (ustekinumab-auub), and Pyzchiva (ustekinumab-ttwe).

2025-07-01added_maximum_allowed_quantities_hcpcs

Added maximum allowed quantities by HCPCS for multiple products (examples: J9038 for Niktimvo; Q9999 for Otulfi; Q9996/Q9997 for Pyzchiva; Q9998 for Selarsdi; Q5133/Q5135 for tocilizumab biosimilars; Q5137/Q5138 for Wezlana).

Policy Summary

PayerUnitedHealthcare

PolicyMaximum Dosage and Frequency

Policy CodePolicy 2025D0034AR

Change TypeAdded HCPCS/NDC maximums & products

Effective DateJul 1, 2025

Next Review DateN/A

SourceLink

On This Page

Upper dose limits for adults are based on the 95th percentile for weight/BSA (140 kg / 2.71 m^2)

Per-administration maximum (example entries)

PiaSky (crovalimab-akkz)Per administration = 1500 mg (policy lists 150 HCPCS units at 10 mg/unit)

Rituxan (rituximab)Example per-administration conversion: 500 mg/m2 maps to HCPCS unit limits (policy shows rituximab maximums of 150 HCPCS units for listed presentations)

Vyepti (eptinezumab)Per administration = 300 mg (policy lists 300 HCPCS units where 1 mg per unit defined)

Examples of Maximum Allowed quantities

Ocrevus (ocrelizumab) NDCMaximum Allowed = 20 mL (Ocrevus 300 mg/10 mL vial mapping)

Opdivo (nivolumab) NDCMaximum Allowed = 40 mL (Opdivo 100 mg/10 mL vial example)

Soliris (eculizumab) NDCMaximum Allowed = 120 mL (300 mg/30 mL vial examples)

Vyvgart (efgartigimod) NDCMaximum Allowed = 60 mL (Vyvgart 400 mg/20 mL vial example)

Reclast (zoledronic acid) NDCMaximum Allowed = up to 100 mL for some infusion presentations (also 5 mL for 4 mg/5 mL vials)

Maximum Allowed Frequency examples

Intravitreal agentsMaximum of 12 doses per year per eye for many intravitreal agents (e.g., Avastin, Lucentis, Eylea, Pavblu)

Actemra (tocilizumab)For giant cell arteritis: administered once every 4 weeks

Beovu (brolucizumab)Initial monthly x3 then every 8–12 weeks thereafter; maximum 12 doses/year/eye

Neulasta / pegfilgrastim biosimilarsAdministered once every 2 weeks for oncology use (as listed for products like Fulphila, Nyvepria)

Botox (onabotulinumtoxinA)Administered no more frequently than every 12 weeks

Intravitreal dosing per eye

Intravitreal dosing capMaximum of 12 doses per year per eye for ranibizumab, aflibercept, faricimab and similar intravitreal agents

Typical intravitreal monthly scheduleInitial once-monthly dosing for up to 3 months (then individualized maintenance intervals)

Alternative extended regimensSome products allow reduction to every 8–12 weeks after loading; annual maximum remains 12 doses/eye

Upper dose threshold (weight/BSA)

95th percentile adult weightUpper dose threshold used = 140 kg

95th percentile adult BSAUpper dose threshold used = 2.71 m^2

ApplicationThese thresholds define the adult upper dose cap when calculating product-specific maximums unless product-specific maxima differ

Bill using the exact NDC(s) listed for the product when selecting NDC billing.
NDC quantities/volumes (mL, vials, or units) in the "Maximum Allowed Quantities for National Drug Code (NDC) Billing" tables must be followed; exceeding these may trigger prior authorization or denial.

Prior Authorization

Prior Authorization — Code Specificity

Prior authorization review may be required when dosing (per administration) or dosing frequency exceeds the product-specific maximums documented in this policy. For prior authorization, identify the exact applicable code being used (HCPCS/Q-code or NDC/labeler-package code) so the request can be matched to the policy limits.

PA requests should reference the exact HCPCS/Q-code or NDC being administered so reviewers can verify against the listed maximums.
Requests exceeding HCPCS unit or NDC quantity limits may require PA or may be denied/adjusted during claims processing.

Documentation Required

Documentation — General Guidance

No specific documentation requirements (for example, required weight/BSA fields, clinical notes templates, or specific lab results) are specified in this excerpt. Providers should follow usual plan prior authorization instructions and submit clinical justification when requesting exceptions.

This policy excerpt does not list mandatory documentation elements (e.g., weight/BSA) although providers are encouraged to include weight or BSA when dosing justification is relevant.
If requesting doses above typical labeling or the policy maximums, include clear clinical rationale and supporting documentation with the PA request.

Step Therapy

Step Therapy — Not Specified

No step therapy rules or step requirements are specified in this policy excerpt. Step therapy, if applicable, will be defined in product-specific coverage policies and benefit plan documents rather than in this maximum dosing/frequency policy.

There are no explicit step therapy requirements in this section.
Refer to product-specific medical benefit drug policies or the member’s benefit plan for any step therapy requirements.

Denial Risk

Denial Risk and Coverage Note

Claims that use codes or NDCs not listed in the policy, or that exceed newly added maximum allowed quantities, may fail to match updated mappings and may be subject to denial or payment adjustment. Inclusion of a code in the policy is informational and does not by itself guarantee coverage — verify member benefits.

Using an unlisted HCPCS/Q-code or NDC may prevent automatic matching to the policy limits and increase denial risk.
Exceeding the policy maximum dosage/frequency without supporting justification is considered not medically necessary and may be denied.

HCPCS conversionsPolicy shows 10 mg per HCPCS unit for bevacizumab-coded entries

Botox (onabotulinumtoxinA) — 600 units

Botox (onabotulinumtoxinA) maximum600 units per administration (Maximum Allowed = 600 HCPCS units; J0585)

Frequency guidanceAdministered no more frequently than every 12 weeks (see Maximum Allowed Frequencies)

NDC presentationExamples include 100-unit vials (NDC listings in NDC section)

Trastuzumab products — 8 mg/kg

Trastuzumab products maximum8 mg/kg per administration (example Maximum Allowed = 126 HCPCS units at 10 mg/unit for listed J/Q codes)

Multiple biosimilars listedHerceptin and multiple trastuzumab biosimilars (Q-codes) have the same per-kg maximums recorded in the HCPCS table

NDC vial countsNDC section shows Herceptin 150 mg vial maximum allowed = 8 vials for certain NDCs

Ocrevus (ocrelizumab) — 600 mg

Ocrevus (ocrelizumab) maximum600 mg per administration (Maximum Allowed = 600 HCPCS units; J2350)

NDC volume mappingNDC listing maps Ocrevus 300 mg/10 mL vial to Maximum Allowed = 20 mL for some NDCs

Dosing frequencyAdministered initially and 2 weeks later, then every 6 months thereafter (see Maximum Allowed Frequencies)

PiaSky (crovalimab-akkz) — 150 HCPCS units

PiaSky (crovalimab-akkz) maximum150 HCPCS units per administration (policy lists 1500 mg = 150 HCPCS units at 10 mg/unit; J1307)

HCPCS unit conversionPolicy records PiaSky as 10 mg per HCPCS unit for the listed HCPCS mapping

Policy historyPiaSky included in HCPCS maximums table (see Maximum Allowed Quantities by HCPCS Units)

Reclast / Zoledronic Acid — 5 HCPCS units

Reclast / Zoledronic Acid maximum5 HCPCS units per administration (policy lists Reclast 5 mg = 5 HCPCS units; J3489)

NDC presentationsSome Reclast NDCs have Maximum Allowed = 5 mL for 4 mg/5 mL vials, and other infusion presentations up to 100 mL

HCPCS unit definitionReclast entry maps 1 mg per HCPCS unit in the HCPCS table

Onpattro (patisiran) — 300 HCPCS units

Onpattro (patisiran) maximum300 HCPCS units per administration (policy lists 30 mg = 300 HCPCS units at 0.1 mg per unit; J0222)

NDC mappingOnpattro NDC examples in NDC section include 10 mg/5 mL vials with Maximum Allowed = 15 mL for some NDCs

HCPCS unit conversionPolicy lists Onpattro HCPCS unit as 0.1 mg per unit in table mapping

Amvuttra (vutrisiran) — 25 HCPCS units

Amvuttra (vutrisiran) maximum25 HCPCS units per administration (policy lists 25 mg = 25 HCPCS units; J0225)

HCPCS unit definitionAmvuttra listed with 1 mg per HCPCS unit in the HCPCS table

Indication-specific frequencyAdministered once every 3 months for hATTR polyneuropathy (see Maximum Allowed Frequencies)

Soliris (eculizumab) — 600 HCPCS units

Soliris (eculizumab) maximum600 HCPCS units per administration (policy lists 1200 mg = 600 HCPCS units at 2 mg/unit; J1299/J? mapping)

NDC mappingSoliris NDC examples list 300 mg/30 mL vials with Maximum Allowed = 120 mL for certain NDCs

HCPCS unit conversionPolicy shows 2 mg per HCPCS unit for Soliris entries

Botox (onabotulinumtoxinA) — 6 vials

Botox per NDC (vial count)Maximum Allowed = 6 vials for specified NDC presentations (100 unit vials example)

HCPCS mappingBotox HCPCS maximum is 600 units per administration (J0585) and NDC vial limits align with HCPCS units

Billing noteWhen billing by NDC, use specified NDC and do not exceed listed vial counts per policy

Herceptin (trastuzumab) — 8 vials

Herceptin (trastuzumab) vial countMaximum Allowed = 8 vials for 150 mg vial NDCs (policy NDC section)

Relation to HCPCS capHCPCS table lists trastuzumab maximum 8 mg/kg with 126 HCPCS units mapping for 10 mg/unit listings

Multiple biosimilarsHerceptin biosimilars and vial-size entries have corresponding NDC maximums listed in the NDC section

Hemlibra — 6 mL

Hemlibra maximum volumeMaximum Allowed = 6 mL (Hemlibra 60 mg/0.4 mL mapping in NDC section)

Presentation mappingHemlibra listed with 60 mg/0.4 mL presentations and NDC-level maximums in the NDC table

Billing implicationClaims exceeding listed mL may be denied or adjusted per policy

Herceptin (150 mg vial) — 8 vials

Herceptin 150 mg vial (NDC) maximumMaximum Allowed = 8 vials for listed 150 mg vial NDCs

HCPCS correspondenceHCPCS trastuzumab entries reflect per-kg maximums and convert to HCPCS unit maxima in the HCPCS table

Provider billing noteWhen billing by NDC, use the specified NDC and adhere to the NDC vial maximums

Neulasta (pegfilgrastim 6 mg/0.6 mL PFS) — 0.6 mL

Neulasta (pegfilgrastim) PFS volumeMaximum Allowed = 0.6 mL for 6 mg/0.6 mL prefilled syringe presentations (e.g., NDC 55513-0190-01)

Biosimilar parityPegfilgrastim biosimilars (Fulphila, Nyvepria, Ziextenzo, etc.) are listed with similar 0.6 mL maximums

Frequency guidancePegfilgrastim products commonly administered once every 2 weeks (see Maximum Allowed Frequencies)

Rituxan (500 mg/50 mL vial) — 150 mL

Rituxan (500 mg/50 mL) volumeMaximum Allowed = 150 mL for listed 500 mg/50 mL vial NDCs

HCPCS mappingRituxan HCPCS maximums (e.g., J9312) show 150 HCPCS units for certain presentations mapped to 10 mg/unit conversions

NDC-level documentationProviders should submit the specific NDC and mL billed per policy NDC documentation guidance

Soliris (eculizumab 300 mg/30 mL vial) — 120 mL

Soliris (eculizumab) 300 mg/30 mL vial volumeMaximum Allowed = 120 mL for certain NDCs (e.g., 25682-0001-01)

HCPCS maximum relationHCPCS entries list Soliris maximums based on mg and units (600 HCPCS units at 2 mg/unit) which correspond to NDC volume limits

Billing cautionClaims exceeding listed mL or HCPCS units may be denied or require adjustment per policy

Tezspire (210 mg/1.91 mL) — 1.91 mL

Tezspire (tezepelumab) prefilled pen volumeMaximum Allowed = 1.91 mL for 210 mg/1.91 mL prefilled pen or PFS (NDC 55513-0123-01; 55513-0112-01)

Frequency contextTezspire maximum frequency entries are listed in Maximum Allowed Frequencies (e.g., dosing per asthma indication)

NDC billing noteWhen billing by NDC, providers must use the specified NDC(s) and adhere to the listed mL maximums

Multiple NDC-specific maximums

NDC-specific maximums noteMultiple products have NDC-specific Maximum Allowed quantities; see NDC code groups for the precise numeric values per NDC

Examples providedPolicy includes many NDC examples with exact mL/vial maxima (see NDC tables across the policy)

Billing implicationClaims that exceed NDC-specific maximums may be denied or adjusted; providers must document exact NDCs billed

ranibizumab, aflibercept, faricimab and similar intravitreal agents

Intravitreal agents annual capranibizumab, aflibercept, faricimab and similar intravitreal agents — Maximum of 12 doses per year per eye

Representative productsIncludes ranibizumab (Lucentis/Cimerli/Byooviz), aflibercept (Eylea/Pavblu), faricimab (Vabysmo/related J-codes)

ApplicabilityApplies to many ophthalmic indications (nAMD, DME, RVO-related ME) as listed in Maximum Allowed Frequencies section

Niktimvo (axatilimab-csfr) — maximum allowed quantities and frequencies added

Niktimvo (axatilimab-csfr) additionsPolicy history: maximum allowed quantities and frequencies added; HCPCS code J9038 and specific NDCs enumerated in policy history

Where recordedSee Policy History/Revision Information entries adding J9038 and NDCs 50881-0012-10, 50881-0023-11, 50881-0034-12

Operational impactAdded maximums imply enforceable HCPCS/NDC limits for Niktimvo per the policy

Otulfi (ustekinumab-aauz) — maximum allowed quantities added

Otulfi (ustekinumab-aauz) additionsPolicy history: maximum allowed quantities added; HCPCS Q9999 and NDCs 65219-0824-01, 65219-0826-26, 65219-0828-05 enumerated

NDC maximumsOtulfi NDC entries list small-volume PFS maximums (0.5–1 mL) and larger vial presentations with higher mL limits in NDC table

Policy sectionSee Maximum Allowed Quantities for National Drug Code (NDC) Billing and Policy History

Pyzchiva (ustekinumab-ttwe) — maximum allowed quantities added

Pyzchiva (ustekinumab-ttwe) additionsPolicy history: maximum allowed quantities added; HCPCS Q9996/Q9997 and NDCs 61314-0651-01, 61314-0652-01, 61314-0654-94 listed

NDC-level maximaPyzchiva PFS presentations listed with Maximum Allowed = 0.5 mL in NDC tables

HCPCS mappingHCPCS Q9996/Q9997 entries added to Applicable Codes with maximums

Selarsdi (ustekinumab-aekn) — maximum allowed quantities added

Selarsdi (ustekinumab-aekn) additionsPolicy history: maximum allowed quantities added; HCPCS Q9998 and NDCs 51759-0505-32, 51759-0607-32, 51759-0708-13 listed

NDC examplesSelarsdi NDCs appear in the NDC additions list within policy history entries

HCPCS inclusionQ9998 added to Applicable HCPCS codes with maximums

Tofidence (tocilizumab-bavi) — maximum allowed quantities added

Tofidence (tocilizumab-bavi) additionsPolicy history: maximum allowed quantities added; HCPCS Q5133 and NDCs 64406-0022-01, 64406-0023-01, 64406-0024-01 listed

HCPCS mappingQ5133 maps to tocilizumab-bavi entries with unit conversions consistent with Actemra listings

Policy locationSee Policy History/Revision Information for added HCPCS/NDC maxima

Tyenne (tocilizumab-aazg) — maximum allowed quantities added

Tyenne (tocilizumab-aazg) additionsPolicy history: maximum allowed quantities added; HCPCS Q5135 and NDCs 65219-0590-04, 65219-0592-10, 65219-0594-20 listed

Relation to ActemraTyenne entries correspond to tocilizumab biosimilar mappings similar to Actemra maximums in HCPCS table

Administrative noteHCPCS/NDC additions are in Policy History and Applicable Codes sections

Wezlana (ustekinumab-auub) — maximum allowed quantities added

Wezlana (ustekinumab-auub) additionsPolicy history: maximum allowed quantities added; HCPCS Q5137/Q5138 and NDCs (multiple) enumerated

NDC list examplesWezlana NDCs include 84612-0055-01, 84612-0066-01, 84612-0076-01, etc., added to NDC lists

Maximum frequency additionsPolicy history notes maximum allowed frequencies were added for Wezlana where applicable

Pavblu (aflibercept-ayyh) — maximum allowed frequencies added

Pavblu (aflibercept-ayyh) frequency additionsPolicy history: maximum allowed frequencies added; Pavblu entries mirror aflibercept dosing with maximum of 12 doses/year per eye

Typical regimenInitial monthly dosing for first 20 weeks then q8 weeks maintenance for certain indications (maximum 12/year/eye)

Policy locationSee Maximum Allowed Frequencies and Policy History for Pavblu additions

Multiple listed products — Maximum allowed frequencies/quantities added

Multiple product additionsPolicy history: multiple listed products had maximum allowed frequencies/quantities added; consult the policy for product-specific numeric limits

Examples includedAdded products include Niktimvo, Otulfi, Pavblu, Pyzchiva, Selarsdi, Tofidence, Tyenne, Wezlana and others

Action for providersReview the policy's Applicable Codes and NDC lists for exact numeric limits per product

PiaSky (crovalimab) loading: One IV loading dose on Day 1 followed by four weekly SC loading doses (Days 2, 8, 15, 22); maintenance begins Day 29 and is administered every 4 weeks.loading then q4wk maintenance

Follow product label for PNH loading and maintenance schedule.

inv-86: Initial therapy

Initial therapy coverage relies on approved labeling and dosing within established maximums

Initial therapy conforms to labeling: Initial dosing must conform to FDA‑approved prescribing information or evidence‑based compendia and must not exceed product‑specific maximums based on weight/BSA.see product labeling and policy thresholds

Requests for initial dosing above established maximums lack supporting evidence and may be denied.

Continuation therapy compliance: Continuation therapy is appropriate when ongoing dosing remains within product‑specific maximums and the clinical indication is unchanged and responding to therapy.see product thresholds and maximum frequencies

If prior dosing exceeded policy maximums, continuation may not be approved without justification and supporting evidence.

Note

Site of care not specified; drugs listed for the medical benefit

Site of care is not specified in the excerpt; the drugs are included on the medical benefit list and are typically administered in infusion centers, offices, or hospital outpatient settings as clinically appropriate.

For payment and billing, use the standard medical benefit place of service corresponding to where the drug was administered.
Confirm site‑of‑care restrictions in the member's benefit plan if needed.

Provider implicationPrior authorization and coverage determinations reference Maximum Frequency to assess dosing requests

Maximum Frequency — administration interval and annual maximum

Administration interval and annual capMaximum Frequency includes recommended administration interval and any annual maximum dosing (e.g., Maximum of 12 doses per year per eye for intravitreal agents)

Example regimensLucentis/ranibizumab: monthly dosing with maximum 12/year/eye; Pavblu/aflibercept: initial monthly then q8 weeks maintenance, max 12/year/eye

Policy useMaximum Frequency entries guide PA and claims review for frequency-based denials or adjustments

Upper dose limit — definition

Upper dose limit definitionUpper dose limit is defined by product-specific maximums and—when deriving an adult cap—by the 95th percentile adult weight (140 kg) and BSA (2.71 m^2)

Product precedenceProduct-specific maximums (FDA labeling or compendia) take precedence over general percentile-derived caps

Clinical rationalePolicy states clinical evidence supports dosing up to these maxima but not beyond; exceeding may increase adverse events without benefit

2025-07-01added_maximum_allowed_quantities_ndc

Added maximum allowed quantities for specific NDCs for Niktimvo, Otulfi, Pyzchiva, Selarsdi, Tofidence, Tyenne, and Wezlana (NDC lists enumerated in policy history).

2025-07-01added_maximum_allowed_frequencies

Added maximum allowed frequencies for Niktimvo (axatilimab-csfr), Otulfi (ustekinumab-aauz), and Pavblu (aflibercept-ayyh).

2025-07-01added_applicable_codes

Added HCPCS codes (J9038, Q5133, Q5135, Q5137, Q5138, Q5147, Q9996, Q9997, Q9998, Q9999) and multiple NDCs to the Applicable Codes section to support billing and enforcement of quantity/frequency limits.