Medicare Advantage Prior Authorization for Chemotherapy and Related Cancer Therapies
Beginning Jan. 1, 2021, we’ll require prior authorization for outpatient injectable chemotherapy and related cancer therapies for members with a cancer diagnosis for Medicare Advantage plans including Medica HealthCare Plans, Preferred Care Partners and UnitedHealthcare West plans (noted by “West” on the back of the members ID card).
We’ll continue to require prior authorization for these outpatient injectable chemotherapy and related cancer therapies for UnitedHealthcare Medicare Advantage health plan members, including AARP® MedicareComplete®, Care Improvement Plus®, UnitedHealthcare Dual Complete® and UnitedHealthcare® Group Medicare Advantage plans.
Optum, an affiliate company of UnitedHealthcare, will help manage these prior authorization requests. Members in institutional special needs plans and Erickson Advantage® plans don’t require prior authorization under this requirement.
If a Medicare Advantage plan member, including those with Medica HealthCare plans, Preferred Care Partners and UnitedHealthcare West plans (noted by “West” on the back of the members ID card), receives injectable chemotherapy drugs or related cancer therapies in an outpatient setting between Oct. 1, 2020, and Dec. 31, 2020, you don’t need to request prior authorization until you administer a new chemotherapy drug or related cancer therapy. We’ll authorize the chemotherapy regimen the member was receiving prior to Jan. 1, 2021. The authorization will be effective until Dec. 31, 2021.
Injectable chemotherapy drugs that require prior authorization:
Injectable chemotherapy drugs (J9000 - J9999)
Injectable chemotherapy drugs that have a Q code
Injectable chemotherapy drugs that have not yet received an assigned code and will be billed under a miscellaneous Healthcare Common Procedure Coding System (HCPCS) code will require prior authorization
Colony-stimulating factors when requested for use to treat a cancer diagnosis requires prior authorization:
J1442 Filgrastim (Neupogen®)
J1447 Tbo-filgrastim (Granix®)
J2505 Pegfilgrastim (Neulasta®)
J2820 Sargramostim (Leukine®)
Q5101 Filgrastim, bio similar (Zarxio®)
Q5108 Pegfilgrastim-jmdb (Fulphila™)
Q5110 Filgrastim-aafi (Nivestym™)
Q5111 Pegfilgrastim-cbqv, biosimilar, (Udenyca™)
Q5120 Pegfilgrastim-bmez (Ziextenzo®)
Colony-stimulating factors that have not yet received an assigned code and will be billed under a temporary or miscellaneous HCPCS code
Bone-modifying agent when requested for a cancer diagnosis requires prior authorization:
Prior authorization is NOT required for the following*:
Oral chemotherapy drugs, which are covered under a member’s pharmacy benefit plan
Use of chemotherapy drugs for non-cancer diagnosis
Note: Adding a new injectable chemotherapy drug, colony-stimulating factor or denosumab to a regimen will require a new prior authorization request.
How We Make Decisions About Prior Authorization
Prior authorization is a process we use to help improve care experiences, outcomes and the cost of care for our plan members. We cover chemotherapy, associated drugs and treatments when Medicare coverage criteria are met. We cover chemotherapy, immunotherapy and hormonal agents when medically indicated and used according to Food and Drug Administration (FDA)-approved indications, or as part of an anticancer chemotherapeutic regimen or cancer treatment regimen.
UnitedHealthcare follows Medicare coverage guidelines, such as national coverage determinations (NCDs), local coverage determinations (LCDs) and other Original Medicare manuals. In the absence of a Medicare LCD, NCD or other Medicare coverage guidance, the Centers for Medicare & Medicaid Services (CMS) allows a Medicare Advantage Organization (MAO) to create its own coverage determinations. MAOs are able to use objective evidence-based rationale that focuses on industry-leading evidence from specialty society research and studies.
In the absence of a Medicare NCD or LCD, we use National Comprehensive Cancer Network® (NCCN®) guidelines to review prior authorization requests and claims for coverage of chemotherapy drugs administered in an outpatient setting. NCCN provides independent, evidence-based recommendations for cancer treatment and is a CMS-recognized compendium. You can view their guidelines at nccn.org > NCCN Guidelines®.
How to Request Prior Authorization
To submit an online request for prior authorization, use Prior Authorization and Notification on the UnitedHealthcare Provider Portal to submit your request. To access the tool, sign in to UnitedHealth Care Provider Portal by going to UHCprovider.com and clicking on the Sign In button in the top right corner. Once you’re in the tool, select Oncology, and when prompted, answer the questions about the service type, member type and state.
Please complete all prior authorization requests online. The online system will identify the members who need a prior authorization request submitted.
If you have questions about prior authorizations for UnitedHealthcare members, please call 888-397-8129, 8 a.m. to 5 p.m., local time, Monday through Friday.
*Member coverage documents and health plans may require prior authorization for some non-chemotherapy services. Care providers should contact the Customer Service phone number on the back of the member’s ID card for more information. If you have questions about oral chemotherapy drugs, please contact the member’s Pharmacy Benefit Plan by calling the number on the back of the member’s ID card.
Note: For members in plans managed by MDX Health®, Lifeprint, OptumCare® and Wellmed®, please follow the delegate’s process for notification.
NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN® and NCCN GUIDELINES® are trademarks (“Marks”) of the National Comprehensive Cancer Network, Inc.