Medicare: Prior authorization required for oncology anti-emetics

Effective Jan. 3, 2022, 4 anti-emetic drugs will require prior authorization for UnitedHealthcare Medicare Advantage members with a cancer diagnosis.

This change is only for members of benefit plans requiring prior authorization for outpatient injectable chemotherapy. However, this change doesn’t affect outpatient injectable chemotherapy prior authorization requirements, only requirements for anti-emetic drugs.

You’ll find more information about the chemotherapy prior authorizations on our Prior Authorization for Chemotherapy and Related Cancer Therapies page.

Preferred products

Aloxi® (palonosetron), Emend®, Kytril® (granisetron) and Zofran® (ondansetron) will be preferred anti-emetic products. The Medicare Part B Step Therapy Program Policy will be updated Jan. 3, 2022, and will have more information about the preferred products.

These anti-emetic codes will require prior authorization starting Jan. 3, 2022:

HCPCS code

Description

J0185

Injection, aprepitant, 1 mg

J1453

Injection, fosaprepitant, 1 mg

J1454

Injection, fosnetupitant 235 mg and palonosetron 0.25 mg

J1627

Injection, granisetron, extended-release, 0.1 mg

Submitting a prior authorization request

Please complete all notifications online. Sign in to the UnitedHealthcare Provider Portal and select the Prior Authorization and Notification tool. Choose Oncology, and fill out the information about the service type, member type and state.

You don’t have to request a prior authorization if the member received these anti-emetic drugs between Oct. 1, 2021, and Jan. 2, 2022, in an outpatient setting for a cancer diagnosis. For these members, we’ll authorize the anti-emetic drug the member was receiving until June 30, 2022, unless you make a change in treatment. You’ll request a new prior authorization if you make a change on or after Jan. 3, 2022.

Questions?

If you have questions about your chemotherapy and cancer-related treatment prior authorization requests, please call Optum at 888-397-8129, 8 a.m.–5 p.m. local time, Monday–Friday. 

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