Prior authorization for anti-emetics

Effective July 1, 2021, prior authorization is required for 8 anti-emetics codes for members with a cancer diagnosis. (Prior authorization requirements for outpatient injectable chemotherapy are not affected by this addition.)

This requirement is for UnitedHealthcare Community Plan, Exchange and commercial plan members who require prior authorization today for outpatient injectable chemotherapy*:

  • Golden Rule Insurance Company  
  • Neighborhood Health Partnership
  • MAMSI Life and Health Insurance Company
  • MD Individual Practice Association, Inc.
  • Optimum Choice, Inc.
  • UnitedHealthcare commercial plans, excluding Indemnity/Options PPO
  • UnitedHealthcare Insurance Company of the River Valley
  • UnitedHealthcare Life Insurance Company
  • UnitedHealthcare of the Mid-Atlantic, Inc
  • UnitedHealthcare Plan of the River Valley, Inc.
  • UnitedHealthcare Value and Balance Exchange
  • UnitedHealthcare Community Plans in California, Maryland, Michigan, Mississippi, New Jersey, Ohio, Rhode Island
*Note: Certain specialty medical injectable drug programs and updates will not be implemented at this time for providers practicing in Rhode Island, with respect to certain commercial members, pursuant to the Rhode Island regulation: 230 -RICR-20-30-14. UnitedHealthcare encourages providers practicing in Rhode Island to call in to confirm if prior authorization is required. This exception does not apply to Medicaid and Medicare.

Preferred products

Preferred products are Emend®, Kytril® and Zofran®. For more information about preferred products, see the medical policies listed below.

Coverage determination guidelines

On July 1, 2021, the Medical Benefit Drug Policy titled Anti-Emetics for Oncology will be available at:

Prior to July 1, 2021, the policy can be accessed from:

How to submit prior authorization

If the member received anti-emetic drugs in an outpatient setting for a cancer diagnosis from April 1, 2021, through June 30, 2021, you DO NOT need to submit a prior authorization request until a new anti-emetic drug will be administered.

We will authorize the anti-emetic drug the member was receiving prior to July 1, 2021, and the authorization will be effective until Dec. 31, 2021, unless a change in treatment is needed.

Please complete all notifications online. Sign into the UnitedHealthcare Provider Portal using your Optum ID and select the Prior Authorization and Notification tool. Once you are in the tool, select Oncology, and when prompted, answer the questions about the service type, member type and state. You can submit authorizations for anti-emetics on June 18, 2021, in advance of the July 1, 2021, requirement.

Questions?

For online requests, call 888-397-8129, 8 a.m.–5 p.m., Monday–Friday local time. Visit Prior Authorization for Chemotherapy and Related Cancer Therapies for more information.

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