CurrentUnitedHealthcarePolicy CS2025D0990W

Pharmacy Benefit Drugs (for Arizona Only)

Defines UnitedHealthcare Community Plan of Arizona reimbursement policy requiring certain high-cost injectable specialty drugs be billed and reimbursed only under the outpatient pharmacy benefit (not on medical professional or outpatient facility claims). Applies to providers and facilities serving Arizona members.

Policy Summary

PayerUnitedHealthcare

PolicyPharmacy Benefit Drugs (for Arizona Only)

Policy CodePolicy CS2025D0990W

Change TypeRevised listmultiple additions

Effective DateSep 1, 2025

Next Review Date

Key ActionSubmit claims for listed injectable specialty drugs on outpatient pharmacy claims; medical professional and facility claims for those HCPCS/J/Q codes will be denied.

SourceLink

POLICY UPDATE CHANGES

Revised list of specialty drugs that will be denied from paying on a medical professional and outpatient facility claim.

Added Alhemo (HCPCS codes C9399, J3490, and J3590) to the denied-on-medical list.

Added Epysqli (HCPCS code Q5151) to the denied-on-medical list.

Added Hemgenix (HCPCS code J1411) to the denied-on-medical list.

Added Hympavzi (HCPCS code J7172) to the denied-on-medical list.

Added Qfitlia (HCPCS codes C9399, J3490, and J3590) to the denied-on-medical list.

Applicable Codes section: Added HCPCS codes J1411, J7172, and Q5151.

Arizona-onlyjurisdiction applicability

Denied on medical claimsreimbursement stance

Multiple HCPCScodes enumerated

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Pharmacy-only Reimbursement Criteria

Pharmacy-only reimbursement criteria

Listed specialty injectable drugs identified by HCPCS/J/Q codes are not reimbursable on medical professional (CMS-1500) or outpatient facility (UB-04) claims and must be billed under the outpatient pharmacy benefit.

If the service is one of the specialty injectable drugs listed in the policy (identified by HCPCS/J/Q codes in the Coverage Rationale/Applicable Codes), THEN the service is not reimbursable on medical professional (CMS-1500) or outpatient facility (UB-04) claims and must be billed and reimbursed under the outpatient pharmacy benefit.

This requirement applies to network and non-network physicians, other qualified health care professionals, and network and non-network facilities serving UnitedHealthcare Community Plan of Arizona members.

Per AHCCCS direction for the Catastrophic Reinsurance Program, biologic/high-cost specialty drugs included in that program must be reimbursed on a pharmacy claim form; UnitedHealthcare Community Plan of Arizona aligns with that requirement.

If a listed drug lacks a specific J- or Q-code and is submitted on a professional or UB claim using miscellaneous codes J3490, J3590, or C9399, the claim is not reimbursable (deny on medical claim; require outpatient pharmacy claim submission).

Applicable HCPCS / J / Q Codes

Representative HCPCS/Codes referenced (not exhaustive)HCPCSNot Covered

J1411	Injection, etranacogene dezaparvovec-drlb, per therapeutic dose
J7172	Injection, marstacimab-hncq, 0.5 mg
Q5151	Injection, eculizumab-aagh (epysqli), biosimilar, 2 mg
J3490	Unclassified drugs
J3590	Unclassified biologics
C9399	Unclassified drugs or biologicals

Billing channel threshold — pharmacy-only reimbursement

Billing channel thresholdReimbursement only via outpatient pharmacy claim; medical professional (CMS-1500) and outpatient facility (UB-04) claims for the listed specialty injectable drugs will be denied.

ScopeApplies to UnitedHealthcare Community Plan of Arizona members, network and non-network physicians, other qualified health care professionals, and facilities.

Regulatory alignmentAligns with AHCCCS Catastrophic Reinsurance Program requirement that biologic/high-cost specialty drugs be reimbursed on a pharmacy claim form.

Claim forms affectedCMS-1500 (professional) and UB-04 (facility) and their electronic equivalents — these channels will be denied for listed drugs.

Effective date for revised list09/01/2025 (policy history notes revised list of specialty drugs denied on medical claims).

Billing & Submission Requirements for Providers

Denial Risk

Billing channel requirement - Denial risk

Providers must submit claims for the injectable specialty drugs listed in the Coverage Rationale on outpatient pharmacy claims (pharmacy benefit). These drugs will be denied when submitted on professional (CMS-1500) or facility (UB-04) medical claims.

Affected: specialty biologic/high-cost injectable drugs identified by HCPCS/Q-codes in the policy.
Applies to: network and non-network physicians and facilities, including non-network authorized and percent of charge contract providers.

Billing Rule

Coding clarification for miscellaneous codes

When a drug product listed in the Coverage Rationale does not have its own specific J- or Q-code, do NOT submit it on a professional or facility (UB) medical claim using miscellaneous codes. Submissions using J3490, J3590, or C9399 on professional/UB claims for these pharmacy-benefit specialty drugs are not reimbursable.

Key Code Definitions

Miscellaneous (J3490 / J3590 / C9399) — coding guidance

When to useJ3490, J3590, or C9399 may be submitted only when a listed drug lacks a specific J- or Q-code, but such submissions on professional (CMS-1500) or UB claims are not reimbursable.

Code descriptions (representative)J3490 = Unclassified drugs; J3590 = Unclassified biologics; C9399 = Unclassified drugs or biologicals.

Submission impactUse of these miscellaneous codes on professional or outpatient facility claims for drugs identified in the Coverage Rationale will result in denial of reimbursement.

Relation to pharmacy benefitIf no specific HCPCS J- or Q-code exists and miscellaneous codes are used, the claim still must be billed under the outpatient pharmacy benefit to be eligible for reimbursement.