- Identified by “West” on the back of the member’s insurance ID card
Note: For members in plans managed by MDX Health ® , Lifeprint, OptumCare ® and Wellmed ® , please follow the delegate’s process for notification.
Prior authorization decisions for Medicare and retirement plans
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 can 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.
Resources
Commercial Policies
- Oncology Medication Clinical Coverage
- Antiemetics for Oncology
- Denosumab (Prolia® & Xgeva®)
- White Blood Cell Colony Stimulating Factors
Medicare Advantage Policies
Additional Resources
Training
Oral chemotherapy
Prior authorization requirements
Expand All add_circle_outline Oral chemotherapy prior authorization expand_moreThe Optum ® Cancer Guidance Program (CGP) manages prior authorization requests for oral chemotherapeutics for most members with UnitedHealthcare commercial plans and UnitedHealthcare Individual Exchange plans. To be eligible, members must have pharmacy benefits administered by Optum Rx.
| Starting Nov. 1, 2023, we’ll require all prior authorization submissions for covered oral chemotherapeutics to be submitted using CGP. Since this change may require your office to make adjustments to your administrative process, we suggest you start submitting your prior authorization requests through the CGP today. The option to use the CGP became available in 2022 to simplify the prior authorization process for these medication drugs. |
Please see the following table for which these plans do and don’t require oral chemotherapy prior authorization through the CGP:
| Required | Not required |
|---|---|
| UnitedHealthcare Individual Exchange plans (all states) | UnitedHealthcare Golden Rule |
| UnitedHealthcare commercial plans | UnitedHealthcare Student Resource |
| UnitedHealthcare All Savers ® plans | UnitedHealthcare Sierra/Health Plan of Nevada ® |
| UnitedHealthcare Neighborhood Health Plan | UnitedHealthcare International |
| UnitedHealthcare River Valley Plan | UnitedHealthcare West Region |
| UnitedHealthcare Oxford Benefit Management℠ plans |
Non-participating plans will continue to request prior authorizations through Optum Rx. If a request for an oral chemotherapeutic is made in the Cancer Guidance Program for a non-participating group, the program will direct you to the member’s pharmacy benefit manager.
Coverage determination guidelines expand_moreWe recognize indications and uses of oral oncology medications listed in the National Comprehensive Cancer Network Drugs and Biologics Compendium with categories of evidence and consensus of 1, 2A and 2B as proven. We’ve determined categories of evidence and consensus of 3 are unproven. We may require supply limits and/or step therapy for certain products.
Resources
- 2024 Prescription Drug List
- Clinical Program Drug Step Therapy – Commercial
- Clinical Pharmacy and Specialty Drugs Prior Authorization Programs
- Quantity Supply Limits per Copay Medication List - UnitedHealthcare commercial plans
- Quantity Duration Supply Limits per Duration Medication List - UnitedHealthcare commercial plans
Submitting your prior authorization request
Expand All add_circle_outline Prior authorization guidelines expand_moreThe following guidelines also apply to prior authorizations to both oral and injectable chemotherapy:
- You’ll need to submit a request using your One Healthcare ID and the Prior Authorization and Notification Tool if a new prior authorization is needed
- You don’t need to submit a new prior authorization request for a treatment plan that’s already approved
- The Cancer Guidance Program will direct you to the member’s pharmacy benefit manager for any oral/topical agents if the member isn’t in scope for the integrated solution
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.
If you have questions, please call 888-397-8129 from 8 a.m. to 5 p.m. local time, Monday–Friday.
Approval and response process expand_moreWe’ll approve authorizations that follow the National Comprehensive Cancer Network (NCCN) regimens at the time of the request. We respond in 3–5 days to requests for pediatric chemotherapy regimens, rare cancers or chemotherapy regimens that aren’t recommended by the NCCN if you provide supporting documentation at the time of the request.
National Comprehensive Cancer Network (NCCN) guidelines
We use the National Comprehensive Cancer Network (NCCN) guidelines as independent recommendations for evidence-based cancer treatment. Medical oncologists perform the reviews.
- You can view all eligible NCCN-recommended chemotherapy regimens during the prior authorization process
- You can submit clinical information during the prior authorization process for members with medical contraindications to an NCCN-recommended regimen
- Expedite the review process by including the relevant clinical details when requesting prior authorization
- Submit clinical information in a text box (e.g., provide a brief description of why a certain chemotherapy agent cannot be given) and upload relevant documentation for the request during the submission process
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.
Footnotes
1. Some member benefit plans require a primary care physician to initiate a referral to a specialist. Members may also have a specific network service area that reflects the needs of the targeted population.
Insurance coverage provided by or through UnitedHealthcare Insurance Company, All Savers Insurance Company, Oxford Health Insurance, Inc. or their affiliates. Health Plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California, UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Texas, LLC, UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc., Oxford Health Plans (NJ), Inc. and Oxford Health Plans (CT), Inc. or other affiliates. Administrative services provided by United HealthCare Services, Inc., OptumRx, OptumHealth Care Solutions, LLC, Oxford Health Plans LLC or their affiliates.
