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Prior Authorization for Outpatient Injectable Chemotherapy and Colony-Stimulating Factors

Our Injectable Chemotherapy Prior Authorization Program aims to improve the quality of care while reducing service denials for UnitedHealthcare members undergoing cancer treatment.

It requires prior authorization for injectable outpatient chemotherapy administered in an outpatient setting including but not limited to intravenous, intravesical and intrathecal for a cancer diagnosis.

Starting Oct. 1, 2017, colony-stimulating factors (CSF) administered to patients with a cancer diagnosis, and who are receiving injectable chemotherapy in an outpatient setting, will also require prior authorization. This requirement applies to all benefit plans that currently require prior authorization for outpatient injectable chemotherapy outlined in the table below under Health Plan Effective Dates

Injectable chemotherapy drugs that require prior authorization:

  • Chemotherapy injectable drugs (J9000 - J9999), Leucovorin (J0640), Levoleukovorin (J0641)
  • Chemotherapy injectable drugs that have a Q code
  • Chemotherapy injectable 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
  • All outpatient injectable chemotherapy drugs started after the chemotherapy prior authorization effective date

Colony-stimulating factors that require prior authorization as of Oct.1, 20173

  • J1442 filgrastim (Neupogen)
  •  J1447 tbo-filgrastim (Granix)
  • J2505 pegfilgrastim (Neulasta)
  • J2820 sargramostim (Leukine)
  • Q5101 filgrastim, bio similar (Zarxio)

Prior authorization is not required for4:

  • Radio-therapeutic agents (e.g., Zevalin and Xofigo)
  • 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 to a regimen will require a new authorization.

How to Request Injectable Chemotherapy Prior Authorization

For UnitedHealthcare Commercial and UnitedHealthcare Community Plan members:
To submit an online request for prior authorization for the Injectable Chemotherapy Program, log in to Link and access the Prior Authorization and Notification app (or use button below). From the app, select Oncology.

We request you attempt to complete all prior authorization requests online. If you have questions regarding authorizations for UnitedHealthcare members, please call 866-889-8054, 7 a.m. to 7 p.m., Monday through Friday.

For UnitedHealthcare Oxford members:
To submit an online request for prior authorization for the Injectable Chemotherapy Program, log into OxfordHealth.com > Submit Chemotherapy Prior Authorization Request > Click Continue > Click Continue to be redirected to UnitedHealthcare oncology authorization intake website.

Please complete all prior authorization requests online. If you have questions regarding authorizations for UnitedHealthcare Oxford members, please call 877-773-2884, 7 a.m. to 7 p.m., Monday through Friday.

The online system will identify the members who require a prior authorization for injectable chemotherapy.

Additional Information
If you have program questions and need more information, please email unitedoncology@uhc.com.

UnitedHealthcare uses National Comprehensive Cancer Network (NCCN) guidelines as independent recommendations for evidence-based cancer treatment.

  • 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 contra-indications 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 (for example, 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
  • Data shows after treatment is rendered with a prior authorization in place, there is a reduction in claims being denied

Authorizations that follow NCCN regimens will be approved at the time of the request.

Requests for pediatric chemotherapy regimens, rare cancers, or chemotherapy regimens that are not NCCN-recommended will receive a response in three to five days if necessary supporting documentation is provided at the time of the request.

 

UnitedHealthcare benefit plans typically require prior authorization for injectable chemotherapy. The following lists show the effective date of the prior authorization requirement.

  • UnitedHealthcare Commercial plans, excluding Indemnity/Options PPO – June 1, 2015

  • UnitedHealthcare Community Plan Arizona Members: Arizona Health Care Cost Containment System/Medicaid and Developmentally Disabled - October 1, 2015

  • UnitedHealthcare Community Plan Delaware Members: Delaware Community Plan, excluding Long Term Care and UnitedHealthcare Dual Complete (HMO SNP) - January 1, 2017

  • UnitedHealthcare Community Plan Florida Members – May 17, 2014

  • UnitedHealthcare Community Plan Maryland Members: HealthChoice- April 1, 2016

  • UnitedHealthcare Community Plan Tennessee Members: TennCare - June 1, 2016

  • UnitedHealthcare Community Plan Washington Members: Apple Health - May 1, 2016

  • UnitedHealthcare Community Plan Michigan Members: Medicaid, excluding CSHCS and UnitedHealthcare Dual Complete (HMO SNP) - October 1, 2016

    UnitedHealthcare Community Plan Mississippi Members: Mississippi Coordinated Access Network (MSCAN) and Mississippi Children's Health Insurance Program (MSCHIP), excludes  UnitedHealthcare Dual Complete (HMO SNP) - October 1, 2016

  • UnitedHealthcare Community Plan New Jersey: New Jersey FamilyCare, this change does not impact members enrolled in the Dual Complete One plan - January 1, 2017

  • UnitedHealthcare Community Plan New York Members: Medicaid Managed Care (MMC), Child Health Plus (CHPlus), Health and Recovery Plan (HARP) otherwise known as Wellness4Me, and Essential Plan. UnitedHealthcare Dual Complete® (Medicare Advantage plan), UnitedHealthcare Dual Advantage (Medicaid Advantage) and Managed Long Term Care (UnitedHealthcare Personal Assist) are excluded from this requirement. - February 1, 2017

  • UnitedHealthcare Community Plan Ohio Members: Medicaid - October 1, 2016

  • UnitedHealthcare Community Plan Pennsylvania Members: Medicaid and CHIP - February 1, 2017

  • UnitedHealthcare Community Plan Texas Members: CHIP, STAR, STAR+PLUS, and STAR Kids: does not apply to UnitedHealthcare Connected (Medicare and Medicaid Plan) and UnitedHealthcare Dual Complete HMO SNP. - January 1, 2017

  • UnitedHealthcare Community Plan Wisconsin Members: Badger Care - October 1, 20163

  • UnitedHealthcare Life Insurance Company2,  select group members - June 1, 2015

  • UnitedHealthcare Oxford Commercial Plans1 – February 1, 2016

  • Golden Rule Insurance Company2, select group numbers – June 1, 2015

  • Neighborhood Health Partnership – May 17, 2014
  1. Coverage decisions for chemotherapy requests for Rhode Island UnitedHealthcare Oxford members and chemotherapy requests by Rhode Island physicians for UnitedHealthcare Oxford members will be determined by UnitedHealthcare Oxford, not eviCore.
  2. Some members coverage documents 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.
  3. If a member receives a colony-stimulating factor in an outpatient setting for a cancer diagnosis between July 1, 2017 and Sept. 30, 2017, a prior authorization request is needed if a new chemotherapy drug or colony-stimulating factor is administered to the member. We’ll authorize the colony-stimulating factor that the member was receiving during the July through September 2017 timeframe, and the authorization will be effective until the end of the chemotherapy regimen approval date.
  4. 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. For questions about oral chemotherapy drugs, contact the member’s Pharmacy Benefit Plan.