We recently mailed select oncology practices their Peer Comparison Reports. Our goal is help support you by sharing how your data compares to other oncology practices – please review your report.
For more information, go to UHCprovider.com/peer or email physician_engagement@uhc.com.
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 Health Plan Effective Dates.
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 portal by going to UHCprovider.com and clicking on the 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.
For Kansas Medicaid Providers (Community and State/KanCare), please submit all prior authorization requests, including for radiology/cardiology/oncology and radiation oncology through the regular PAAN tool. Once in the PAAN tool, select 'Check by Code' to verify if authorization is needed and 'Create New Submission' to submit a new request.
UnitedHealthcare uses National Comprehensive Cancer Network (NCCN) guidelines as independent recommendations for evidence-based cancer treatment.
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 Community Plan is listed in alphabetical order and includes the state Medicaid name, if applicable.
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.
This is an expansion of our existing “Requirement to Use a Participating Specialty Pharmacy Provider for Certain Medications”, as outlined in the UnitedHealthcare Administrative Guide.
This expanded requirement applies to UnitedHealthcare commercial plans including but not limited to:
The requirement does not apply to:
For more information including FAQs, visit Specialty Pharmacy – Medical Benefit Management (Provider Administered Drugs) and click Medication Sourcing Expansion
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