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Prior Authorization for Chemotherapy, Colony-Stimulating Factors and Denosumab

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.

On June 1, 2018, we will begin requiring prior authorization when Denosumab (HCPCS code J0897) a bone modifying agent, is recommended as part of treatment for a cancer diagnosis.

Colony-stimulating factors (CSF) administered to patients with a cancer diagnosis, and who are receiving injectable chemotherapy in an outpatient setting, have required  prior authorization since Oct. 1 2017.
 
These prior authorization requirements apply to all benefit plans outlined in the table below under Health Plan Effective Dates. 

Go to Prior Authorization and Notification App >

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)

Bone modifying agent that requires prior authorization as of  June 1, 20184:

  • J0897 Denosumab

Prior authorization is NOT required for the following5:

  • 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 or colony stimulating factor to a regimen will require a new authorization.

How to Request Prior Authorization

For UnitedHealthcare Commercial and UnitedHealthcare Community Plan members:

To submit an online request for prior authorization, sign in to Link and access the Prior Authorization and Notification app. From the app, select Oncology.

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

Go to Prior Authorization and Notification App >

For UnitedHealthcare Oxford members:

To submit an online request for prior authorization, go to OxfordHealth.com > Providers > Submit Chemotherapy Prior Authorization Request > Click Continue > Click Continue again to be redirected to UnitedHealthcare oncology authorization intake website.

Please complete all prior authorization requests online. If you have questions about 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.

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. Following are our benefit plans that require prior authorization listed by line of business. They’re listed in order of the most current effective date of the prior authorization requirement, then in alphabetical order thereafter. For UnitedHealthcare Community Plan, the state Medicaid name is included, if applicable.

UnitedHealthcare Commercial Plans

  • UnitedHealthcare Oxford commercial plans1 - Effective Feb. 1, 2016
  • Golden Rule Insurance Company2, select group numbers - Effective June 1, 2015
  • UnitedHealthcare commercial plans, excluding Indemnity/Options PPO - Effective June 1, 2015
  • UnitedHealthcare Life Insurance Company2,  select groups - Effective June 1, 2015
  • Neighborhood Health Partnership - Effective May 17, 2014

UnitedHealthcare Community Plan

  • UnitedHealthcare Community Plan in New York - Effective Feb. 1, 2017
    • Medicaid Managed Care (MMC), Child Health Plus (CHPlus),
    • Health and Recovery Plan (HARP) otherwise known as Wellness4Me,
    • Essential Plan
    • UnitedHealthcare Dual Complete® (Medicare Advantage plan)
    • UnitedHealthcare Dual Advantage (Medicaid Advantage)
    • Excludes Managed Long Term Care (UnitedHealthcare Personal Assist)
  • UnitedHealthcare Community Plan in Pennsylvania - Effective Feb. 1, 2017
    • Medicaid and CHIP
  • UnitedHealthcare Community Plan in New Jersey - Effective Jan. 1 2017
    • New Jersey FamilyCare  
    • Excludes UnitedHealthcare Dual Complete® ONE (HMO SNP)
  • UnitedHealthcare Community Plan in Texas - Effective Jan. 1,2017
    • CHIP, STAR, STAR+PLUS, and STAR Kids  
    • Excludes UnitedHealthcare Connected® (Medicare and Medicaid Plan) and UnitedHealthcare Dual Complete (HMO SNP)
  • UnitedHealthcare Community Plan in Michigan: Medicaid - Effective Oct. 1, 2016
    • Excludes Children’s Special Health Care Services and UnitedHealthcare Dual Complete (HMO SNP)
  • UnitedHealthcare Community Plan in Mississippi - Effective Oct. 1, 2016  
    • Mississippi Coordinated Access Network (MSCAN)
    • Mississippi Children's Health Insurance Program (MSCHIP),
    • Excludes UnitedHealthcare Dual Complete (HMO SNP)
  • UnitedHealthcare Community Plan in Ohio: Medicaid - Effective Oct. 1, 2016
  • UnitedHealthcare Community Plan in Wisconsin: Badger Care - Effective Oct. 1, 2016
  • UnitedHealthcare Community Plan in Tennessee: TennCare - Effective June 1, 2016
  • UnitedHealthcare Community Plan in Washington: Apple Health - Effective May 1, 2016
  • UnitedHealthcare Community Plan in Maryland: HealthChoice - Effective April 1, 2016
  • UnitedHealthcare Community Plan in Arizona - Oct. 1, 2015
    • Arizona Health Care Cost Containment System/Medicaid
    • Developmentally Disabled
  • UnitedHealthcare Community Plan in Florida - May 17, 2014

Helpful Resources

  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. If the member received denosumab in an outpatient setting from March 1, 2018 through May 31, 2018, you DON’T need to submit a prior authorization request. The prior authorization to cover denosumab the member was receiving prior to June 1, 2018 will be effective until May 31, 2019.
  5. 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.