Does J2468 require prior authorization?

Yes, J2468 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for J2468?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`J2468`, Injection, palonosetron hydrochloride (posfrea), 25 micrograms

HCPCS/CPT

Prior Authorization

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

For non-preferred product approval: documentation of a prior trial (adequate dose and duration) of a preferred NK1 RA or 5HT3 RA and documentation of minimal clinical response to that trial.
Alternatively, for non-preferred product approval: documentation of history of intolerance, contraindication, or adverse event to a preferred NK1 RA or 5HT3 RA, plus physician attestation that the same intolerance/contraindication/adverse event would not be expected with the requested non-preferred product.

Physician attestation (statement in medical record) supporting expectation of superior clinical response with non-preferred product (when trial/failure route used) or supporting that intolerance/contraindication to preferred product would not occur with non-preferred product.

Documentation that oral antiemetics are administered prior to the chemotherapy infusion (when coverage sought under this policy for oral agents) — evidence that medication was given 'at time of chemotherapy' not self-administered at home.

Documentation of the emetogenic risk of the chemotherapy regimen (High, Moderate, Low, Minimal) supporting the need for NK1 RA and/or 5HT3 RA and whether combination therapy is guideline-appropriate.

When coverage for NK1 RA or NK1/5HT3 combination for Moderate emetic risk is requested, documentation of one or more patient-specific risk factors for CINV (younger age <55, female sex, prior CINV, low/no alcohol use, history of motion sickness or morning sickness, high anxiety).

Key Coverage Criteria

Prevention of chemotherapy-induced nausea and vomiting (CINV) due to High Emetic Risk parenteral anticancer agents when an NK1 RA (e.g., Emend, Cinvanti, Varubi) is used in combination with a 5HT3 RA.
Prevention of CINV due to Moderate Emetic Risk parenteral anticancer agents when an NK1 RA is used in combination with a 5HT3 RA and the patient has one or more CINV risk factors (younger age <55 years; female sex; previous history of chemotherapy-induced nausea/vomiting; little or no previous alcohol use; history of motion sickness or morning sickness during pregnancy; high anxiety).
Prevention of CINV due to High Emetic Risk parenteral anticancer agents when a 5HT3 RA (Aloxi, Kytril, Sustol, Zofran) is used in combination with an NK1 RA.
Prevention of CINV due to Moderate Emetic Risk parenteral anticancer agents when a 5HT3 RA is used (standalone option for moderate risk).
Prevention of CINV due to Moderate Emetic Risk parenteral anticancer agents when a 5HT3 RA is used in combination with an NK1 RA and the patient has one or more CINV risk factors (younger age <55 years; female sex; previous history of chemotherapy-induced nausea/vomiting; little or no previous alcohol use; history of motion sickness or morning sickness during pregnancy; high anxiety).
Treatment of breakthrough nausea and/or vomiting due to anticancer agent(s) (5HT3 RAs listed as indicated for this scenario).

4 Active Policies

MODA-ALOXI-C9C3C9D3F8, Palonosetron: Aloxi; Posfrea Ψ

UMR-POL-UMR-antiemetics-oncology, Antiemetics for Oncology

SUREST-POL-SUREST-antiemetics-oncology, Antiemetics for Oncology

UHC-POL-antiemetics-oncology, Antiemetics for Oncology

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J2468, Injection, palonosetron hydrochloride (posfrea), 25 micrograms