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Maximum Dosage and Frequency (for Pennsylvania Only)

UnitedHealthcare·PA · Oncology, Ophthalmology, Rheumatology +3 more·Medical Benefit Drug Policy
Effective date
Oct 1, 2026
We identified it
Sep 2, 2026
Days to comply
—

Summary

UnitedHealthcare Community Plan of Pennsylvania updated maximum dosage and frequency limits for injectable medications effective October 1, 2026. The policy adds 16 new biosimilar and biologic drugs to the covered list, revises dosage limits for 8 existing medications (primarily ophthalmology agents), adds 19 new HCPCS codes, and removes 1 code. Biosimilars and reference biologics are now treated as therapeutically equivalent for dosing purposes.

Action Required

Action needed
By September 15, 2026: Billing team must update claims processing system to add the 19 new HCPCS codes (J2351, J2781, J3263, J9024, J9272, J9275, J9277, J9289, J9298, J9329, J9345, J9999, Q5156, Q5159, Q5161, Q5164, Q5165, Q5166, Q5167, Q5171) with new maximum dosage and frequency limits per UnitedHealthcare's updated policy. Remove HCPCS code C9151 from billing rules. Update dosage limits in system for: Beovu, Byooviz, Cimerli, Eylea, Eylea HD, Lucentis, Pavblu, Susvimo, Syfovre, and Vabysmo. Configure system to treat biosimilars (e.g., Aukelso, Boncresa, Bosaya, Enoby, Jubereq, Ospomyv, Osvyrti, Oziltus, Xbryk, Xtrenbo) as therapeutically equivalent to reference biologics for maximum dosage application. Billing team and coding staff must verify new drug names and NDC mappings in system. Notify providers of maximum allowed quantities by HCPCS units. Claims submitted on or after October 1, 2026 with dosages exceeding new limits will be denied unless supporting medical necessity documentation is provided.

Affected Billing Codes

J2351
J2781
J3263
J9024
J9272
J9275
J9277
J9289
J9298
J9329
J9345
J9999
Q5156
Q5159
Q5161
Q5164
Q5165
Q5166
Q5167
Q5171
C9151
Maximum Dosage and Frequency (for Pennsylvania Only) | UnitedHealthcare | PolicyChanges.app