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Oncology Codes with new PA Requirements

Date: 10/25/17

November 1, 2017

The following drugs have changes to authorization requirements for all providers effective January 1, 2018. These changes apply to Managed Health Services (MHS) members enrolled in Hoosier Care Connect, Hoosier Healthwise, the Healthy Indiana Plan (HIP) and Ambetter plans.

Oncology Codes:

Currently the following drugs do not require authorization for hospitals, hematologists, oncologists, and neurologists. Effective January 1, 2018 the codes below will require prior authorization for all providers.  This change is being implemented to ensure these drugs are being utilized according to NCCN (National Comprehensive Cancer Network®) guidelines. Requests for these drugs will be reviewed using our previously established medical necessity criteria.

  • Adcetris (brentuximab) -  J9042
  • Keytruda (pembrolizumab) – J9271
  • Opdivo (nivolumab) – J9299

Please visit mhsindiana.com for more information on how to submit prior authorization or to check prior authorization requirements for other services.