CurrentUnitedHealthcarePolicy N/A

Therapeutic Equivalent Medications Excluded Drugs (Medical Benefit)

Defines an exclusion policy for certain medical-benefit injectable medications deemed therapeutically equivalent to covered alternatives for UnitedHealthcare commercial plan members; affects prescribing providers and members subject to member benefits and applicable state law.

Policy Summary

PayerUnitedHealthcare

PolicyTherapeutic Equivalent Medications Excluded Drugs (Medical Benefit)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescribe the therapeutically equivalent covered alternative provided by the plan for any excluded medication.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

quarterlyreviews per year

6med changes per year (max)

1alternatives provided

Coverage Criteria — Excluded Medical-Benefit Injectables

Excluded Medications (Medical Benefit)

Medications are excluded when ALL of the following apply:

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.

Certain targeted medical injectables that are administered by health care professionals are excluded from coverage for UnitedHealthcare commercial plan members when they appear on the Medical Benefit Therapeutic Equivalent Medications Excluded Drug List. These exclusions are applied as allowed by member benefits and applicable state law. For each medication excluded, the plan provides a therapeutically equivalent alternative that the provider should prescribe.

Provider Actions and Operational Guidance

Denial Risk

Coverage exclusion triggers denial

Medications listed on the Medical Benefit Therapeutic Equivalent Medications Excluded Drug List are not covered under the member's plan and, unless a coverage exception exists, claims for those excluded medications may be denied.

Excluded medications are subject to denial if billed without an approved coverage exception.

Note

Use of therapeutically equivalent alternative

For every medication excluded from coverage, the plan covers a therapeutically equivalent alternative. Providers should direct patients to the covered alternative medication and prescribe the covered alternative when clinically appropriate.

The excluded list exists to encourage use of lower‑cost, therapeutically equivalent medications.
Providers should transition members to the covered alternative when prior authorization for an excluded medication expires.

Prior Authorization

Prior authorization continuation

Members who already have a prior authorization for an excluded medication may continue to receive that medication until the prior authorization expires or the member’s eligibility changes. Once the prior authorization expires, the prescribing clinician should transition the member to a covered alternative or submit a coverage exception request if clinically necessary.

Continuation allowed only until prior authorization expiration or eligibility change.
Upon expiration, transition to covered alternative or request exception.

Prior Authorization

Predetermination / Prior Authorization

Predetermination (prior authorization) requests for medications excluded from coverage may be submitted using the standard prior authorization/predetermination process.

Submit requests through the plan's standard prior authorization workflow for review.
If a clinical coverage exception is needed, include supporting documentation with the predetermination request.

Background and Rationale

Therapeutically equivalent medications are those judged to have essentially the same efficacy and adverse event profiles as a covered alternative, as determined by the Pharmacy & Therapeutics and Prescription Drug List Management review process. The rationale for this exclusion policy is to direct use to lower‑cost, therapeutically equivalent alternatives while ensuring a covered alternative is available for every excluded product.

Decisions about which injectables to add to the excluded list and their preferred alternatives are made through the Prescription Drug List Management Committee with guidance from the P&T Committee, and exclusions are applied consistent with member plan benefits and applicable state law.

Definitions

Therapeutically equivalent — producing similar therapeutic outcomes and adverse events to a covered alternative as determined by the P&T committee.

DefinitionProducing similar therapeutic outcomes and adverse events to a covered alternative as determined by the UnitedHealthcare Pharmacy & Therapeutics (P&T) Committee.

Decision authorityUnitedHealthcare Pharmacy & Therapeutics (P&T) Committee evaluates medications for therapeutic equivalence after rigorous review.

Final coverage determinationThe Prescription Drug List Management Committee makes final coverage decisions using guidance from the P&T Committee.

Clinical composition of P&T CommitteeIncludes external physicians across specialties, medical directors, and pharmacists who review evidence and determine equivalence.

Practical implicationIf judged therapeutically equivalent, an excluded medication will have a covered alternative provided by the plan for prescribing guidance.

Continuation of Therapy

Continuation after prior authorization

Continuation of therapy when prior authorization already in place

Continuation allowed: Member may continue excluded medication until prior authorization expires or member eligibility changes

Upon prior authorization expiration the prescribing health care professional must transition the member to another treatment option

Step	Requirement / Action
1	Prescribe the therapeutically equivalent covered alternative provided by the plan for the excluded medication

Site-of-Care Applicability