00781
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- For non-preferred product use, physician attestation that: 1) there is a history of intolerance or contraindication to one of UnitedHealthcare's preferred products; and 2) in the physician's clinical opinion, the same intolerance, contraindication, or adverse event would not be expected to occur with the respective non-preferred product.
- Coverage decisions require reference to the member specific benefit plan document; check member specific benefit plan document and any applicable federal or state mandates before using this policy.
- Refer to the Diagnosis-Specific Criteria section and any drug-specific coverage policy referenced in Related Policies for required clinical documentation (this policy instructs to refer to those sections/policies for diagnosis-specific documentation but does not list additional tests or records itself).
Key Coverage Criteria
- Coverage will be provided for the UnitedHealthcare preferred product contingent on the coverage criteria in the Diagnosis-Specific Criteria section.
- Members new to therapy will be required to utilize the UnitedHealthcare preferred product unless they meet the criteria in this section.
- Treatment with the respective non-preferred product specified in the Non-Preferred Drug Products table below is medically necessary for proven indications when both of the following are met: - History of intolerance or contraindication to one of the UnitedHealthcare's preferred products; and - Physician attests that, in their clinical opinion, the same intolerance, contraindication, or adverse event would not be expected to occur with the respective non-preferred product.
- Applicable HCPCS code provided for reference: J3285 - Injection, treprostinil, 1 mg (i.e., treprostinil injection billed with J3285).
- Preferred UnitedHealthcare medical drug products listed (covered subject to Diagnosis-Specific Criteria): Treprostinil 20mg/20mL Solution for Injection (00781-3420), Treprostinil 50mg/20mL Solution for Injection (00781-3425), Treprostinil 100mg/20mL Solution for Injection (00781-3427), Treprostinil 200mg/20mL Solution for Injection (00781-3430) (Sandoz Inc. a Novartis Company).
1 Active Policy
UHC-POL-provider-administered-preferred-products — Provider Administered Drugs – Preferred Products
Related Codes
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