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January 01, 2023

Injectable anti-emetics prior authorization changes

UnitedHealthcare Community Plan of Pennsylvania will require prior authorization for certain injectable anti-emetics

Starting Jan. 1, 2023, certain injectable anti-emetic agents will require prior authorization. Additionally, before obtaining a prior authorization for a non-preferred injectable antiemetic agent, providers must first try one of the following preferred injectable agents. (See table.)

A prior authorization request for any non-preferred medication will go through a medical review. If there is no clear evidence that the preferred product was tried and was not successful prior to the prior authorization submission, it could result in unnecessary denials or delays in care.

If the beneficiary does not meet the clinical review guidelines, but in the professional judgement of the physician reviewer the services are medically necessary to meet the medical needs of the beneficiary, the request for prior authorization will be approved.

Preferred Agent Name HCPCS Code Non-Preferred Agent Name HCPCS Code
Aloxi®/Palonosetron J2469 Fosaprepitant J1453
Cinvanti® J0185 Fosnetupitant-Palonosetron J1454
Granisetron Q0166 Foscarnet Sodium J1456
Ondansetron S0119    

To submit a prior authorization

  • Sign in to the UnitedHealthcare Provider Portal
  • Click on the Prior Authorization tool
  • Select Create a new notification or prior authorization request
  • Enter the required information on the submission site

Questions?

Access the Optum Rx® Pharmacy website for tools and resources. For information about the new process or for answers to specific questions, call Optum at 888-397-8129, 8 a.m.–5 p.m. local time, Monday–Friday.

PCA-1-22-04208-C&S-News_12142022
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