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.
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.
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.
Note: For members in plans managed by MDX Health®, Lifeprint, OptumCare® and Wellmed®, please follow the delegate’s process for notification.
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.org.
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.
The following guidelines also apply to prior authorizations to both oral and injectable chemotherapy:
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.
We use the National Comprehensive Cancer Network (NCCN) guidelines as independent recommendations for evidence-based cancer treatment. Medical oncologists perform the reviews.
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.