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Medicare Advantage Prior Authorization for Select Oncology Medications

Audience: Prescribing Providers

In an effort to reduce costs while maintaining high safety, efficacy, and quality standards, we are implementing new prior authorization (PA) requirements on select medical benefit oncology medications for members enrolled in Medicare Advantage plans. For members enrolled in these plans, select biosimilars will be the preferred medications.

This change is effective January 1, 2023, for new starts only. While use of the biosimilars is not required for members already established on therapy, they can begin the transition to the biosimilars, if you believe it is medically appropriate.

What is a Biosimilar?

A biosimilar is a biologic product that is approved after it has been demonstrated as highly similar to an FDA-approved biologic product, known as a reference product, and has no clinically meaningful differences in terms of safety and effectiveness from the reference product. Only minor differences in clinically inactive components are allowed in biosimilars.

To learn more about biosimilars, please visit the FDA website. The FDA website also provides resources for patients; we encourage you to review these materials before prescribing any prescription medication.  

Prescribing & Billing Requirements

To ensure prescribing accuracy and correct claim submissions, follow the prescribing and billing requirements outlined on the following pages. Please share this important information with your billing office/billing service and anyone within your practice who should be aware. All claims must include the Healthcare Common Procedure Coding System (HCPCS) and National Drug Code (NDC).

When billing the NDC information, please include a valid 11-digit NDC, a valid unit of measure and the number of units to be considered for reimbursement. Failure to follow these instructions will result in denied claims and/or potential delays in reimbursement, depending on the line of business.

GENERIC NAME DRUG NAME HCPCS CODE NDC PA REQUIRED FOR MEDICARE ADVANTAGE PA REQUIRED FOR COMMERCIAL AND EXCHANGE PA REQUIRED FOR MMC, CHP, HARP, AND ESSENTIAL PLAN
Bevacizumab

Mvasi™

 

Q5107

 

55513020601

55513020701

 

No

 

No

 

No

 

Zirabev™

 

Q5118

 

00069031501

00069034201

 

No

 

No

 

No

 

Avastin®

 

J9035

 

50242006001

50242006010

50242006101

50242006110

 

Yes

 

Yes

 

Yes

 

 

Alymsys®

 

Not yet assigned

 

70121175407

70121175401

70121175501

70121175507

 

Yes

 

Yes

 

Yes

 

Trastuzumab

Kanjinti™

 

Q5117

 

55513013201

55513014101

 

No

 

No

 

No

 

Trazimera™

 

Q5116

 

00069030501

00069030801

00069030601

 

No

 

No

 

No

 

Herceptin®,

 

Herceptin Hylecta™

 

J9355,

 

J9356

 

50242013201

50242013210

50242033301

50242007701

 

Yes

 

Yes

 

Yes

 

Herzuma®

 

Q5113

 

63459030343

63459030547

63459030741

 

Yes

 

Yes

 

Yes

 

Ogivri®

 

Q5114

 

67457084550

67457084744

67457099115

 

Yes

 

Yes

 

Yes

 

Ontruzant®

 

Q5112

 

00006503302

78206014701

78206014801

78206014799

00006503301

00006503401

00006503402

 

Yes

 

Yes

 

Yes

 

 

GENERIC NAME DRUG NAME HCPCS CODE NDC PA REQUIRED FOR MEDICARE ADVANTAGE PA REQUIRED FOR COMMERCIAL AND EXCHANGE PA REQUIRED FOR MMC, CHP, HARP, AND ESSENTIAL PLAN
Rituximab

Ruxience™

 

Q5119

 

00069023801

00069024901

 

No

 

No

 

No

 

Truxima®

 

Q5115

 

63459010310

63459010450

 

No

 

No

 

No

 

Rituxan®,

 

Rituxan Hycela®

 

J9312,

 

J9311

 

50242005110

50242005121

50242005306

50242010801

50242010901

 

Yes

 

Yes

 

Yes

 

Riabni®

 

Q5123

 

55513022401

55513032601

 

Yes

 

Yes

 

Yes

 

NOTE: Preferred Biosimilars are in BOLD and DO NOT require prior authorization.  Non-preferred drugs will require PA and will only be approved if there is medical justification why preferred biosimilars cannot be used. MMC=Medicaid Managed Care, CHP=Child Health Plus, HARP=Health and Recovery Plan

When submitting a PA request, please include all of the following relevant clinical information:

  • Diagnosis
  • Clinical justification for why the preferred biosimilar is not the best choice for your patient.

This policy change was reviewed and approved by our Pharmacy & Therapeutics (P&T) Committee, which is comprised of local physicians and pharmacists who are not employed by the Health Plan.

Please visit our Policies & Guidelines section for drug policies, and the Authorizations tab to access prior authorization information.

If you have questions or concerns, please contact your Provider Relations representative.

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