Prior Authorization for Injectable Chemotherapy and Related Cancer Therapies
To help ensure our member benefit coverage is medically appropriate, we regularly evaluate our medical policies, clinical programs and health benefits based on the latest scientific evidence and specialty society guidance. To support these goals, we require notification/prior authorization for injectable outpatient chemotherapy and related cancer therapies administered in an outpatient setting, including but not limited to intravenous, intravesical and intrathecal for a cancer diagnosis.
These prior authorization requirements apply to all benefit plans outlined in the table under HealthPlan Effective Dates.
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:1
J1442 Filgrastim (Neupogen®)
J1447 Tbo-filgrastim (Granix®)
J2506 Pegfilgrastim (Neulasta®)
J2820 Sargramostim (Leukine®)
Q5101 Filgrastim, bio similar (Zarxio®)
Q5108 Pegfilgrastim-jmdb (Fulphila™)
Q5110 Filgrastim-aafi (Nivestym™)
Q5120 Pegfilgrastim-bmez, Biosimilar (Ziextenzo™)
Q5111 Pegfilgrastim-cbqv, biosimilar, (Udenyca™)
Q5122 Pegfilgrastim-apgf, biosimilar, (Nyvepria)
Colony stimulating factors that have not yet received an assigned code and will be billed under a temporary or miscellaneous HCPCS code will require prior authorization
Bone Modifying Agent When Requested for a Cancer Diagnosis2:
Anti-Emetic Drugs When Requested for a Cancer Diagnosis
J0185 aprepitant (Cinvanti®)
J1453 fosaprepitant (Emend®)
J1454 fosnetupitant and palonosetron (Akynzeo®)
J1627 granisetron, extended-release (Sustol®)
Prior Authorization is NOT Required for the Following3:
Anti-emetic drugs, which are covered under a member’s pharmacy benefit plan
Use of chemotherapy drugs for non-cancer diagnosis
Use of antiemetics for non-cancer diagnosis
Adding a new injectable chemotherapy drug, colony stimulating factor, anti-emetic or denosumab to a regimen will require new authorization.
Additional details regarding prior authorization requirements for radiopharmaceuticals can be found here.
To submit an online request for prior authorization, use the Prior Authorization and Notification tool in the UnitedHealthcare Provider Portal to submit your request. To access the tool, sign in to the UnitedHealthcare 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.
All eligible NCCN-recommended chemotherapy regimens are displayed during the prior authorization process.
Physicians can submit clinical information during the authorization process for members with medical contraindications to an NCCN-recommended regimen.
To expedite the review process, it’s important for care providers to include the relevant clinical details when requesting prior authorization.
Care providers can submit clinical information in a text box (e.g., provide a brief description of why a certain chemotherapy agent cannot be given) and upload relevant documentation for the request during the submission process.
Reviews are performed by medical oncologists
Authorizations that follow NCCN regimens will be approved at the time of the request. We respond in three to five days to requests for pediatric chemotherapy regimens, rare cancers or chemotherapy regimens that aren’t NCCN-recommended if necessary supporting documentation is provided at the time of the request.
UnitedHealthcare benefit plans typically require prior authorization for injectable chemotherapy. The benefit plans that do require prior authorization are listed by line of business in alphabetical order.
UnitedHealthcare Commercial Plans (Prior Authorization requirements for Anti-Emetics – Effective July 1, 2021)
All Savers – Effective January 1, 2018
Golden Rule Insurance Company (select group numbers4) - Effective June 1, 2015
Neighborhood Health Partnership - Effective May 17, 2014
MAMSI Life and Health Insurance Company - Effective August 1, 2019
MD Individual Practice Association, Inc. - Effective August 1, 2019
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®.
Starting with dates of service on June 7, 2021, outpatient hospitals must obtain certain oncology supportive care medications from the participating specialty pharmacies we indicate, except as otherwise authorized by us.
Member coverage documents and health plans may require prior authorization for some non-chemotherapy services. If you have questions, contact the Customer Service phone number on the back of the member’s ID card. Contact the member’s Pharmacy Benefit Plan for questions about oral chemotherapy drugs.
Some member benefit plans require a primary care physician to initiate a referral to a specialist. Members may also have a specific network service area that reflects the needs of the targeted population.
Insurance coverage provided by or through UnitedHealthcare Insurance Company, All Savers Insurance Company, Oxford Health Insurance, Inc. or their affiliates. Health Plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California, UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Texas, LLC, UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc., Oxford Health Plans (NJ), Inc. and Oxford Health Plans (CT), Inc. or other affiliates. Administrative services provided by United HealthCare Services, Inc., OptumRx, OptumHealth Care Solutions, LLC, Oxford Health Plans LLC or their affiliates.