New York: Update to injectable cancer therapy effective date
In the July Network Bulletin, we published the New York: Injectable cancer therapy update with an effective date of Oct. 1, 2021.We’re delaying the announced transition of the prior authorization requests to Optum and the prior authorization requirements.
The new prior authorization process and requirements are now effectiveFeb. 1, 2022.
Requesting prior authorization
Optum will manage our prior authorization requests for outpatient injectable cancer therapies, including:
Chemotherapy and biologic therapy
This change applies to UnitedHealthcare Community Plan members with a cancer diagnosis in New York. Any active prior authorizations requested using the former process will remain in place.
Submit prior authorization requests online at UHCprovider.com > Prior Authorization and Notification > Oncology. Sign in to the UnitedHealthcare Provider Portal using your One Healthcare ID and select the Prior Authorization and Notification tool. Once you are in the tool, select Oncology and answer the questions about the service type, member type and state.
Medications requiring prior authorization
Effective Feb. 1, 2022, we’ll require prior authorization for the following therapeutic radiopharmaceuticals:
Lutetium Lu 177 (Lutathera®)
Radium RA-233 dichloride (Xofigo®)
Iobenguane I 131 (Azedra®)
All therapeutic radiopharmaceuticals that have not yet received an assigned code and will be billed under a miscellaneous Healthcare Common Procedure Coding System (HCPCS) code
Those therapeutic radiopharmaceuticals can be billed under the following HCPCS codes:
A9590-Iodine I-131, iobenguane, 1 mCi
A9513 Lutetium Lu 177, dotatate, therapeutic, 1 mCi
A9606 Radium RA-223 dichloride, therapeutic, per microcurie
A9699 Radiopharmaceutical, therapeutic, not otherwise classified
On Feb. 1, 2022, we’ll also require prior authorization for the following 5 anti-emetic codes for members with a cancer diagnosis. Prior authorization requirements for outpatient injectable chemotherapy are not affected.
J0185 aprepitant, 1 mg
J1453 fosaprepitant, 1 mg
J1454 fosnetupitant 235 mg and palonosetron 0.25 mg
J1627 granisetron, extended-release, 0.1 mg
J2469 palonosetron HCl, 25 mcg
Preferred products for anti-emetics include Emend®, Kytril® and Zofran®. For more information about preferred products, see the medical policy listed below.
Anti-emetics for oncology coverage determination guidelines
If a member receives therapeutic radiopharmaceuticals and/or anti-emetics for a cancer diagnosis in an outpatient setting between Nov. 1, 2021, and Jan. 31, 2022, you don’t need to request prior authorization until you administer a new therapeutic radiopharmaceutical drug or anti-emetic. We’ll authorize the therapeutic radiopharmaceutical drug and/or anti-emetic the member was receiving prior to Feb. 1, 2022. The authorization will be effective until Jan. 31, 2023.
Other medical benefit drug policies are used for coverage reviews for cancer therapies and cancer supportive drugs, such as the colony-stimulating factors:
Oncology Medication Clinical Coverage Policy
White Blood Cell Colony-Stimulating Factors
These policies include coverage criteria for non-preferred products. If a member receives a non-preferred product in an outpatient setting between Nov. 1, 2021, and Jan. 31, 2022, you don’t need to request a new prior authorization for these products. Those existing authorizations will be honored through their end date.