Specialty medical injectable medication program, requirement and policy updates April 2026
Review the following tables to determine changes to our specialty medical injectable medication programs and drug policy updates for April 2026.
Review the following tables to determine changes to our specialty medical injectable medication programs and drug policy updates.
Review at Launch
The following specialty medical injectable medication has been added to Review at Launch:
| Medication Name | HCPCs Code(s) |
| Loargys® (pegzilarginase-nbln) |
J3490/J3590/C9399 |
Note: Medications added to Review at Launch may not yet be available in the marketplace.
Review the UnitedHealthcare Commercial Plan Review at Launch Medication List. For questions, please contact your broker or UnitedHealthcare representative.
Updates to drug program requirements and drug policies
The following drug program requirements and drug policy updates will be made to UnitedHealthcare commercial business:
| Medication Name | HCPCs Code(s) | Effective Date | Summary of Changes |
| Avtozma® (tocilizumab-anoh) Biosimilar to Actemra® |
Q5156 | 7/1/26 |
|
| Beizray (docetaxel) |
J9174 | 4/1/26 |
|
| Itvisma® (onasemnogene abeparvovec-brve) |
J3490/J3590/C9309 | 7/1/26 |
|
| Jobevne® (bevacizumab-nwgd) |
Q5160 | 4/1/26 |
|
| Keytruda® (pembrolizumab) |
J9271 | 4/1/26 |
|
| Keytruda Qlex® (pembrolizumab and berahyaluronidase alfa-pmph) |
J9277 | 4/1/26 |
|
| Kyxata™ (carboplatin) |
J9278 | 4/1/26 |
|
| Opdivo® (nivolumab) |
J9299 | 4/1/26 |
|
| Opdivo Qvantiq® (nivolumab and hyaluronidase-nvhy) |
J9289 | 4/1/26 |
|
| Unloxcyt® (cosibelimab-ipdl) |
J9275 | 4/1/26 |
|
| Waskyra™ (etuvetidigene autotemcel) |
J3490/J3590/C9399 | 7/1/26 |
|
| Yartemlea® (narsoplimab-wuug) |
J3490/J3590/C9399 | 7/1/26 |
|
UnitedHealthcare will honor all approved prior authorizations on file until the end date on the authorization or the date the member’s eligibility changes. Upon prior authorization renewal, the updated policy will apply.
Note: Certain specialty medical injectable medication programs and updates will not be implemented at this time for providers practicing in Rhode Island, with respect to certain commercial members, pursuant to the Rhode Island regulation: 230-RICR-20-30-14. UnitedHealthcare encourages providers practicing in Rhode Island to call in to confirm if prior authorization is required.
Medication Sourcing for All Outpatient Providers
Effective July 1, 2026, the following specialty medical injectable medication is being added to Medication Sourcing for All Outpatient Providers:
| Medication Name | HCPCs Code(s) | Specialty Pharmacy |
| Itvisma (onasemnogene abeparvovec-brve) |
J3490/J3590/C9309 | TBD |
Medication Sourcing for Outpatient Hospital Providers Only
The following specialty medical injectable medication is being added to Medication Sourcing for Outpatient Hospital Providers Only:
| Medication Name | HCPCs Code(s) | Effective Date | Specialty Pharmacy |
| Starjemza™ (ustekinumab-hmny) Biosimilar to Stelara® |
J3490/J3590/C9399 | 5/1/26 | Amber Specialty Pharmacy |
| Avtozma (tocilizumab-anoh) Biosimilar to Actemra® |
Q5156 | 7/1/26 | TBD |
Review the UnitedHealthcare Commercial Plan Medication Sourcing List.
For questions, please contact your broker or UnitedHealthcare representative.
Update to the “Requirements for Complete Claims and Encounter Data Submission” Protocol for Inpatient Stays with High-Cost Drug Administration
Effective July 1, 2026, UnitedHealthcare is updating the “Unique billing scenarios and requirements” (page 138) in the existing “Requirements for Complete Claims and Encounter Data Submission” Protocol (page 137) by requiring the Healthcare Common Procedure Coding System (HCPCS) and the National Drug Code (NDC) codes on all UnitedHealthcare commercial plan claims with an inpatient place of service when one of the following specialty drugs is administered inpatient:
| Medication Name | Description | HCPCS Code |
| Elevidys® | Injection, delandistrogene moxeparvovec-rokl, per therapeutic dose | J1413 |
| Gamifant® | Injection, emapalumab-lzsg, 1 mg | J9210 |
| Hemgenix® | Injection, etranacogene dezaparvovec-drlb, per therapeutic dose | J1411 |
| Luxturna® | Injection, voretigene neparvovec-rzyl, 1 billion vector genomes | J3398 |
Spinraza® |
Injection, nusinersen, 0.1 mg | J2326 |
| Vyjuvek® | Injection, beremagene geperpavec-svdt for topical administration, containing nominal 5x109 PFU/ml vector genomes, per 0.1 mg | J3401 |
| Zolgensma® | Injection, onasemnogene abeparvovec-xioi, per treatment, up to 5 x 10^15 vector genomes | J3399 |
What you need to know
Inclusion of both the HCPCS and NDC codes on the claim is necessary for UnitedHealthcare to identify the drug administered and determine whether the claim is eligible for payment, including confirming compliance with prior authorization or advance notification requirements and the outcome of any related medical necessity review.
As part of this update, claims that are missing the required HCPCS and NDC information may be denied or may be pended while UnitedHealthcare requests additional documentation, such as an itemized bill, to determine payment eligibility.
Plans this applies to
This change will apply to UnitedHealthcare commercial plans and affiliate plans, including UnitedHealthcare of the Mid-Atlantic, UnitedHealthcare Oxford, Neighborhood Health Partnership, UnitedHealthcare of the River Valley, UnitedHealthcare Freedom Insurance Company and Surest.
Resources
More information about this protocol update can be found, starting July 1, 2026, at UHCprovider.com > Policies and Protocols for Providers > Additional Resources > Protocols.
Questions? We’re here to help.
Connect with us through chat 24/7 in the UnitedHealthcare Provider Portal.
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