UHC Wisconsin Outpatient Injectable Cancer Tx Authorization Program Process Change

September 2018 ~

In November, UnitedHealthcare (UHC) will make changes to the way it manages prior authorization requests for certain outpatient injectable cancer therapy.

Effective November 1, Optum, an affiliate company of UHC, will begin managing the insurer’s prior authorization requests for outpatient injectable cancer therapy, including chemotherapy and biologic therapy, colony stimulating factors and denosumab. These requests were previously managed by eviCore.

According to the notice from UHC, this change applies to UHC Community Plan members with a cancer diagnosis in Florida, Arizona, Maryland, Washington, Tennessee, Michigan, Mississippi, Ohio and Wisconsin. Any active prior authorizations requested via the former process will remain in place.

Prior authorization will continue to be required for:

  • Chemotherapy and biologic therapy injectable drugs (J9000 – J9999), Leucovorin (J0640) and Levoleucovorin (J0641)
  • Chemotherapy and biologic therapy injectable drugs that have a Q code
  • Chemotherapy and biologic therapy injectable drugs that have not yet received an assigned code and will be billed under a miscellaneous Healthcare Common Procedure Coding System (HCPCS) code
  • Colony Stimulating Factors: J2505 (neulasta), J1442 (neupogen), J2820 Leukine® (sargramostim), Q5101 (Filgrastim– biosimilar Zarxio), J1447 Granix (tbofilgrastim)
  • Denosumab (Brand names Xgeva and Prolia): J0897

NOTE: Prior authorization will be required when adding a new injectable chemotherapy drug or cancer therapy to an existing regimen.


Source(s): UnitedHealthcare Network Bulletin September 2018;