Coverage Rationale .............................................................. 1

Applicable Codes .................................................................. 3

recommendation is supported by a level of evidence category. Coverage of White Blood Cell Colony Stimulating Factors

for Chimeric Antigen Receptor (CAR)-T Cell products. Coverage determinations are based on the member’s benefits and

the OptumHealth Transplant Solutions criteria for covered transplants; refer to the Clinical Guideline titled Chimeric

Antigen Receptor T-cell Therapy.

Cancer Diagnosis, Prognosis, and Treatment

expected to occur with the respective non-preferred product

Below are UnitedHealthcare preferred oncology products with therapeutically equivalent and/or biosimilar* non-preferred

products as determined by the UnitedHealthcare P&T Committee:

Phesgo (pertuzumab, trastuzumab, hyaluronidase-zzxf)**

Trazimera (trastuzumab-qyyp) + Perjeta (pertuzumab)

Ogivri (trastuzumab-dkst) + Perjeta (pertuzumab)

Herceptin Hylecta (trastuzumab and hyaluronidase-oysk)

Ruxience (rituximab-pvvr)

Truxima (rituximab-abbs)

(leuprolide acetate for depot suspension - J9217, J1954),

already FDA-approved biological product, known as a reference product, and that there are no clinically meaningful

differences between the biosimilar product and the reference product.

**Phesgo is a combination product of pertuzumab + trastuzumab.

The majority of pediatric patients receive treatments on national pediatric protocols that are quite similar in concept to the

Refer to Preferred Product Criteria for the UnitedHealthcare preferred oncology products that have therapeutically

equivalent and/or biosimilar products available.

a member’s Transplantation Services benefit. Coverage determinations are based on the OptumHealth Transplant

Solutions criteria for covered transplants; refer to the Clinical Guideline titled Chimeric Antigen Receptor T-cell Therapy.

Benefit coverage for an otherwise unproven service for the treatment of serious rare diseases may occur when certain

conditions are met. Refer to the Policy and Procedure addressing the treatment of serious rare diseases.

Medicare may cover outpatient (Part B) drugs that are furnished “incident to” a physician’s service provided that the drugs

are not usually self-administered by the patients who take them. Refer to the Medicare Benefit Policy Manual, Chapter 15,

***Preferred therapy criteria for Medicare Advantage members, refer to Medicare-Part-B-Step-Therapy-Programs.

European Organization for Research and Treatment of Cancer, National Cancer Institute of the United States,

National Cancer Institute of Canada. J Natl Cancer Inst. 2000 Feb 2;92(3):205-16.

This Medical Benefit Drug Policy provides assistance in interpreting UnitedHealthcare standard benefit plans. When

deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific

benefit plan may differ from the standard plan. In the event of a conflict, the member specific benefit plan document

governs. Before using this policy, please check the member specific benefit plan document and any applicable federal or

state mandates. UnitedHealthcare reserves the right to modify its Policies and Guidelines as necessary. This Medical

Benefit Drug Policy is provided for informational purposes. It does not constitute medical advice.

UnitedHealthcare may also use tools developed by third parties, such as the InterQual

administering health benefits. UnitedHealthcare Medical Benefit Drug Policies are intended to be used in connection with

the independent professional medical judgment of a qualified health care provider and do not constitute the practice of

medicine or medical advice.