Transcription of Maximum Dosage and Frequency - UHCprovider.com
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Maximum Dosage and Frequency Page 1 of 19 UnitedHealthcare Commercial Medical Benefit Drug Policy Effective 01/01/2022 Proprietary Information of UnitedHealthcare. Copyright 2022 United HealthCare Services, Inc. UnitedHealthcare Commercial Medica l Benefit Drug Policy Maximum Dosage and Frequency Policy Number: 2022D0034AF Effective Date: January 1, 2022 Instructions for Use Table of Contents Page Coverage Rationale .. 1 Applicable Codes .. 12 Benefit Considerations .. 16 Clinical Evidence .. 16 References .. 17 Policy History/Revision Information.
Avastin ; bevacizumab . 15 mg/kg . J9035 ; 192 HCPCS units (10 mg per unit) Mvasi ; bevacizumab-awwb . 15 mg/kg Q5107 . 192 HCPCS units (10 mg per unit) Zirabev . bevacizumab-bvzr ; 15 mg/kg Q5118 . 192 HCPCS units (10 mg per unit) Aveed ; testosterone undecanoate . 750 mg . J3145 ; 750 HCPCs units (1 mg per unit) Cimzia ; certolizumab pegol ...
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