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Prior Authorization for Injectable Chemotherapy and Related Cancer Therapies

Overview

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.

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Injectable Chemotherapy Drugs that Require Prior Authorization:

  • Injectable chemotherapy drugs (J9000-J9999)
  • Leucovorin (J0640), Levoleucovorin (J0641), levoleucovorin (J0642)
  • Injectable chemotherapy drugs that have a Q code
  • J1950 Leuprolide acetate (for depot suspension)
  • J1952 Leuprolide injectable, camcevi
  • 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 

Colony-Stimulating Factors When Requested for Use to Treat a Cancer Diagnosis:1

  • 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

Bone Modifying Agent When Requested for a Cancer Diagnosis2:

  • J0897 Denosumab

Anti-Emetic Drugs When Requested for a Cancer Diagnosis

  • J0185 aprepitant (Cinvanti®) 
  • J1453 fosaprepitant (Emend®) 
  • J1454 fosnetupitant and palonosetron (Akynzeo®) 
  • J1627 granisetron, extended-release (Sustol®)

Prior Authorization is NOT Required for the Following3:

  • Anti-emetic 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, anti-emetic or denosumab to a regimen will require new authorization.

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

How to Request Prior Authorization

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. 

  • If you have questions about authorizations, please call 888-397-8129, 8 a.m. to 5 p.m. local time, Monday through Friday.

Program Questions & Information

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 contraindications 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 (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.
  • Reviews are performed by medical oncologists

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 Commercial Plans (Prior Authorization requirements for Anti-Emetics – Effective July 1, 2021)

  • All Savers – Effective January 1, 2018
  • Golden Rule Insurance Company (select group numbers4) - 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 
  • 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 groups4) - 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 Anti-Emetics – 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

  • UnitedHealthcare Community Plan in Arizona - Effective October 1, 2015
  • UnitedHealthcare Community Plan of California - Effective April 1, 2019 (Prior Authorization requirements for Anti-Emetics – Effective July 1, 2021)
  • UnitedHealthcare Community Plan in Florida - Effective May 17, 2014
  • UnitedHealthcare Community Plan of Kansas - Effective May 1, 2022
  • UnitedHealthcare Community Plan in Kentucky - Effective January 1, 2021 (Prior Authorization requirements for Anti-Emetics – Effective January 1, 2021)
  • UnitedHealthcare Community Plan in Louisiana - Effective February. 1, 2019
  • UnitedHealthcare Community Plan in Maryland - Effective April 1, 2016 (Prior Authorization requirements for Anti-Emetics – Effective July 1, 2021)
  • UnitedHealthcare Community Plan in Michigan - Effective October 1, 2016 (Prior Authorization requirements for Anti-Emetics – Effective July 1, 2021)
  • UnitedHealthcare Community Plan of Minnesota - - Effective May 1, 2022
  • UnitedHealthcare Community Plan in Mississippi - Effective October 1, 2016 (Prior Authorization requirements for Anti-Emetics – 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 Anti-Emetics – Effective July 1, 2021)
  • UnitedHealthcare Community Plan in New York - Effective February 1, 2017
  • UnitedHealthcare Community Plan in Ohio - Effective October 1, 2016 (Prior Authorization requirements for Anti-Emetics – 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 Anti-Emetics – Effective July 1, 2021)
  • UnitedHealthcare Community Plan in Texas - Effective January 1, 2017
  • UnitedHealthcare Community Plan in Tennessee - Effective June 1, 2016 (Prior Authorization requirements for Anti-Emetics – Effective August 1, 2021)
  • 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

UnitedHealthcare Medicare & Retirement Plan

  • 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.

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 are able to 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 > NCCN Guidelines®.

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:

  • UnitedHealthcare
  • UnitedHealthcare of the River Valley
  • Neighborhood Health Partnership
  • All Savers
  • UnitedHealthcare of the Mid-Atlantic

The requirement does not apply to:

  • UnitedHealthcare Oxford
  • UMR
  • Harvard Pilgrim
  • Student Resources
  • UnitedHealthcare West
  • Sierra plans
  • UnitedHealthOne Golden Rule
  • UnitedHealthcare Value & Balance Exchange Benefit Plans

For more information including FAQs, visit Specialty Pharmacy – Medical Benefit Management (Provider Administered Drugs) and click Medication Sourcing Expansion


Footnotes

  1. Prior authorization requirement effective October 1, 2017.
  2. Prior authorization requirement effective June1, 2018.
  3. 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. 
  4. 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.