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.
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.
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.
UnitedHealthcare uses National Comprehensive Cancer Network (NCCN) guidelines as independent recommendations for evidence-based cancer treatment.
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.
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:
The requirement does not apply to:
For more information including FAQs, visit Specialty Pharmacy – Medical Benefit Management (Provider Administered Drugs) and click Medication Sourcing Expansion
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