Specialty medical injectable medication program, requirement and policy updates July 2026

Review the following tables to determine changes to our specialty medical injectable medication programs and drug policy updates for July 2026.

Review the following tables to determine changes to our specialty medical injectable medication programs and drug policy updates.

Medical Benefit Therapeutic Equivalent Medications – Excluded Drugs

Effective Oct. 1, 2026, the following specialty injectable medications are being added to Medical Benefit Therapeutic Equivalent Medications – Excluded Drugs for UnitedHealthcare commercial business:

Excluded Medication HCPCs Code(s) Therapeutic Class Other Options
Denosumab products – Prolia®  Biosimilars
Bosaya™ 
(denosumab-kyqq)
Q5161 Osteoporosis Prolia, Bildyos®, Enoby™, and Stoboclo®
Conexxence™ 
(denosumab-bnht)
Q5158
Ospomyv™
(denosumab-dssb)
Q5159
Exdensur™
(depemokimab-ulaa)
J2361 Asthma Fasenra™ or Nucala® and Tezspire®
Qivigy®
(immune globulin intravenous, human-kthm)
J1577 Immune Globulin Bivigam®, Cutaquig®, Cuvitru®, Flebogamma® DIF, Gammagard® Liquid, Gammagard™ S/D, Gammaked™, Gammaplex®, Gamunex®-C, Hizentra®, HyQvia®, Octagam®, Privigen®, Xembify®
Yimmugo®
(immune globulin intravenous, human-dira)
J1553

Updates to drug program requirements and drug policies

Effective Oct. 1, 2026, the following drug program requirements and drug policy updates will be made to UnitedHealthcare commercial business:

Medication Name HCPC(s) Summary of Changes
Avlayah™
(tividenofusp alfa-eknm)

J3490/J3590/C9399

  • Add prior authorization/notification in Outpatient Hospital place of service only
Bosaya
(denosumab-kyqq)
Biosimilar to Prolia

Q5161

  • Add prior authorization/notification
  • In states where coverage is not excluded
    • Add as a non-preferred product; must step through Prolia, Bildyos, and Stoboclo prior to coverage
Conexxence
(denosumab-bnht)
Biosimilar to Prolia

Q5158

  • Add prior authorization/notification
  • In states where coverage is not excluded
    • Add as a non-preferred product; must step through Prolia, Bildyos, and Stoboclo prior to coverage
Exdensur
(depemokimab-ulaa)

J2361

  • Add prior authorization/notification
  • In states where coverage is not excluded
    • Add as a non-preferred product; must step through Fasenra or Nucala and Tezspire prior to coverage
    • Add to Site of Care
Kresladi™
(marnetegragene autotemcel)

J3490/J3590/C9399

  • Add prior authorization/notification
  • Managed by Optum Transplant
Loargys®
(pegzilarginase-nbln)

J3490/J3590/C9399

  • Add prior authorization/notification in Outpatient Hospital place of service only
  • Add to Site of Care
Ospomyv
(denosumab-dssb)
Biosimilar to Prolia

Q5159

  • Add prior authorization/notification
  • In states where coverage is not excluded
    • Add as a non-preferred product; must step through Prolia, Bildyos, and Stoboclo prior to coverage
Qivigy
(immune globulin intravenous, human-kthm)

J1577

  • Add prior authorization/notification
  • In states where coverage is not excluded:
    • Add as a non-preferred product; members must step through Bivigam, Cutaquig, Cuvitru, Flebogamma DIF, Gammagard Liquid, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Hizentra, HyQvia, Octagam, Privigen, and Xembify prior to coverage
    • Add to Site of Care

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 programs and updates may not be implemented for some providers or commercial members where prohibited by applicable state insurance mandates or regulations. Providers are encouraged to confirm whether prior authorization or other program requirements apply.

For questions, please contact your broker or UnitedHealthcare representative.

Medication Sourcing for Outpatient Hospital Providers Only
Effective Oct. 1, 2026, the following specialty medical injectable medication is being added to Medication Sourcing for Outpatient Hospital Providers Only for UnitedHealthcare commercial business:

Medication Name

HCPCS Code(s)

Specialty Pharmacy

Avlayah
(tividenofusp alfa-eknm)
J3490/J3590/C9399 Orsini Pharmaceutical Services
Bosaya
(denosumab-kyqq)
Biosimilar to Prolia
Q5161

TBD

Conexxence
(denosumab-bnht)
Biosimilar to Prolia

 Q5158

Amber Specialty Pharmacy

Exdensur
(depemokimab-ulaa)
J2361

Caremark (CVS Specialty)

Loargys®
(pegzilarginase-nbln)

 J3490/J3590/C9399

Orsini Pharmaceutical Services
Ospomyv
(denosumab-dssb)
Biosimilar to Prolia

 Q5159

TBD
Qivigy
(immune globulin intravenous, human-kthm)

 J1577

TBD

Review the UnitedHealthcare Commercial Plan Drugs that Require Sourcing List.

For questions, please contact your broker or UnitedHealthcare representative.

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