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Prior authorization for oral and injectable chemotherapy and related cancer therapies

Overview

We regularly evaluate our medical policies, clinical programs and health benefits based on the latest scientific evidence and specialty society guidance to help ensure our member benefit coverage is medically appropriate.

To support these goals, we require prior authorization for injectable outpatient chemotherapy, oral chemotherapy and related cancer therapies administered in an outpatient setting. These include intravenous, intravesical and intrathecal for a cancer diagnosis.

To submit and manage your prior authorizations, please sign in to the UnitedHealthcare Provider Portal.

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Injectable chemotherapy and related cancer therapies

Program requirements

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  • Injectable chemotherapy drugs (J9000-J9999)
  • Injectable chemotherapy drugs that have a Q code
  • J0640 Leucovorin calcium (Wellcovorin)
  • J0641 Levoleucovorin, not otherwise specified (Fusilev)
  • J0642 Levoleucovorin (Khapzory)
  • J1448 Trilaciclib (Cosela)
  • J1932 Lanreotide (Cipla)
  • J1950 Leuprolide acetate, for depot suspension
  • J1952 Leuprolide (Camcevi)
  • J1954 Leuprolide acetate, for depot suspension (Cipla)
  • J1448 Trilaciclib (Cosela)
  • 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 
  • 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
Note: Prior authorization requirement effective October 1, 2017.
  • J0897 Denosumab
Note: Prior authorization requirement effective June 1, 2018.
  • J0185 aprepitant (Cinvanti®) 
  • J1453 fosaprepitant (Emend®) 
  • J1454 fosnetupitant and palonosetron (Akynzeo®) 
  • J1627 granisetron, extended-release (Sustol®)
  • Antiemetic 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, antiemetic or denosumab to a regimen will require new authorization.

Additional details regarding prior authorization requirements for radiopharmaceuticals can be found here.

Note: 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.

Health plan effective dates

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.

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  • All Savers – Effective January 1, 2018
  • Golden Rule Insurance Company (select group numbers1) – 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 
  • Optimum Choice, Inc. – Effective August 1, 2019 
  • Surest – Effective July 1, 2024
  • UnitedHealthcare Commercial plans, excluding Indemnity/Options PPO – Effective June 1, 2015
  • UnitedHealthcare Insurance Company of the River Valley – Effective August 1, 2019 
  • UnitedHealthcare Life Insurance Company (select groups1) – Effective June 1, 2015  
  • UnitedHealthcare of the Mid-Atlantic, Inc. – Effective August 1, 2019 
  • UnitedHealthcare Oxford commercial plans – Effective February 1, 2016 (Prior Authorization requirements for antiemetics – Effective August 1, 2021)
  • UnitedHealthcare Plan of the River Valley, Inc. – Effective August 1, 2019
  • UnitedHealthcare Value and Balance Exchange – Effective January 1, 2020 
  • UnitedHealthcare Community Plan in Arizona - Effective October 1, 2015
  • UnitedHealthcare Community Plan of California - Effective April 1, 2019 (Prior Authorization requirements for antiemetics – Effective July 1, 2021), Health Plan Sunset Effective December 31, 2022
  • Rocky Mountain Health Plans -  Effective November 1, 2023
  • UnitedHealthcare Community Plan in Florida - Effective May 17, 2014
  • UnitedHealthcare Community Plan of Hawai’i - Effective January 1, 2023 
  • UnitedHealthcare Community Plan of Kansas - Effective May 1, 2022
  • UnitedHealthcare Community Plan in Kentucky - Effective January 1, 2021 (Prior Authorization requirements for antiemetics – Effective August 1, 2021)
  • UnitedHealthcare Community Plan in Louisiana - Effective February. 1, 2019
  • UnitedHealthcare Community Plan in Maryland - Effective April 1, 2016 (Prior Authorization requirements for antiemetics – Effective July 1, 2021)
  • UnitedHealthcare Community Plan in Michigan - Effective October 1, 2016 (Prior Authorization requirements for antiemetics – Effective July 1, 2021), Program Termination September 1, 2022
  • UnitedHealthcare Community Plan in Mississippi - Effective October 1, 2016 (Prior Authorization requirements for antiemetics – Effective July 1, 2021)
  • UnitedHealthcare Community Plan in Nebraska - Effective November 1, 2018
  • UnitedHealthcare Community Plan in New Jersey - Effective January 1, 2017 (Prior Authorization requirements for antiemetics – Effective July 1, 2021)
  • UnitedHealthcare Community Plan of New Mexico – Effective July 1, 2024
  • UnitedHealthcare Community Plan in New York - Effective February 1, 2017 (Prior Authorization requirements for antiemetics - Effective February 1, 2022)
  • UnitedHealthcare Community Plan in Ohio - Effective October 1, 2016 (Prior Authorization requirements for antiemetics – Effective July 1, 2021)
  • UnitedHealthcare Community Plan in Pennsylvania - Effective February 1, 2017
  • UnitedHealthcare Community Plan in Rhode Island - Effective November 1, 2018 (Prior Authorization requirements for antiemetics – Effective July 1, 2021)
  • UnitedHealthcare Community Plan in Tennessee - Effective June 1, 2016 (Prior Authorization requirements for antiemetics – Effective August 1, 2021)
  • UnitedHealthcare Community Plan in Texas - Effective January 1, 2017
  • UnitedHealthcare Community Plan of Virginia - Effective May 1, 2022
  • UnitedHealthcare Community Plan in Washington - Effective May 1, 2016
  • UnitedHealthcare Community Plan in Wisconsin - Effective October 1, 2016
  • AARP MedicareComplete - Effective October 1, 2019
  • Care Improvement Plus - Effective October 1, 2019
  • Preferred Care Network - Effective January 1, 2021
  • Preferred Care Partners - Effective January 1, 2021
  • UnitedHealthcare Dual Complete - Effective October 1, 2019
  • UnitedHealthcare Group Medicare Advantage - Effective October 1, 2019
  • UnitedHealthcare Medicare Advantage - Effective October 1, 2019
  • UnitedHealthcare West plans - Effective January 1, 2021
    • Identified by “West” on the back of the member’s insurance ID card

Note: For members in plans managed by MDX Health®, Lifeprint, OptumCare® and Wellmed®, please follow the delegate’s process for notification.

Prior authorization decisions for Medicare and retirement plans

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 can 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.orgopen_in_new.

Resources

Commercial Policies

Medicare Advantage Policies

Additional Resources

Training

Oral chemotherapy

Prior authorization requirements

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The Optum® Cancer Guidance Program (CGP) manages prior authorization requests for oral chemotherapeutics for most members with UnitedHealthcare commercial plans and UnitedHealthcare Individual Exchange plans. To be eligible, members must have pharmacy benefits administered by Optum Rx.

Starting Nov. 1, 2023, we’ll require all prior authorization submissions for covered oral chemotherapeutics to be submitted using CGP. Since this change may require your office to make adjustments to your administrative process, we suggest you start submitting your prior authorization requests through the CGP today. The option to use the CGP became available in 2022 to simplify the prior authorization process for these medication drugs.

Please see the following table for which these plans do and don’t require oral chemotherapy prior authorization through the CGP:

Required Not required
UnitedHealthcare Individual Exchange plans (all states) UnitedHealthcare Golden Rule
UnitedHealthcare commercial plans UnitedHealthcare Student Resource
UnitedHealthcare All Savers® plans UnitedHealthcare Sierra/Health Plan of Nevada®
UnitedHealthcare Neighborhood Health Plan UnitedHealthcare International
UnitedHealthcare River Valley Plan UnitedHealthcare West Region
UnitedHealthcare Oxford Benefit Management℠ plans  

Non-participating plans will continue to request prior authorizations through Optum Rx. If a request for an oral chemotherapeutic is made in the Cancer Guidance Program for a non-participating group, the program will direct you to the member’s pharmacy benefit manager.

We recognize indications and uses of oral oncology medications listed in the National Comprehensive Cancer Network Drugs and Biologics Compendium with categories of evidence and consensus of 1, 2A and 2B as proven. We’ve determined categories of evidence and consensus of 3 are unproven. We may require supply limits and/or step therapy for certain products.  

Resources

Submitting your prior authorization request

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The following guidelines also apply to prior authorizations to both oral and injectable chemotherapy:

  • You’ll need to submit a request using your One Healthcare ID and the Prior Authorization and Notification Tool if a new prior authorization is needed
  • You don’t need to submit a new prior authorization request for a treatment plan that’s already approved
  • The Cancer Guidance Program will direct you to the member’s pharmacy benefit manager for any oral/topical agents if the member isn’t in scope for the integrated solution

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. 

Go to the Prior Authorization and Notification Tool.

If you have questions, please call 888-397-8129 from 8 a.m. to 5 p.m. local time, Monday–Friday. 

We’ll approve authorizations that follow the National Comprehensive Cancer Network (NCCN) regimens at the time of the request. We respond in 3–5 days to requests for pediatric chemotherapy regimens, rare cancers or chemotherapy regimens that aren’t recommended by the NCCN if you provide supporting documentation at the time of the request.

National Comprehensive Cancer Network (NCCN) guidelines

We use the National Comprehensive Cancer Network (NCCN)open_in_new guidelines as independent recommendations for evidence-based cancer treatment. Medical oncologists perform the reviews.

  • You can view all eligible NCCN-recommended chemotherapy regimens during the prior authorization process
  • You can submit clinical information during the prior authorization process for members with medical contraindications to an NCCN-recommended regimen
    • Expedite the review process by including the relevant clinical details when requesting prior authorization
    •  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

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.

Footnotes

1.     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.