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    v1.0.30
    OpenPayerPolicy UpdatesHematology/Oncology1199SEIU Oncology Medications Prior Auth | OpenPay…
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    Current1199SEIU National Benefit FundPolicy N/A

    Oncology Medications Policy

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    Governs coverage and prior authorization for FDA-approved medications used for direct cancer treatment and specified supportive treatment of cancer-related symptoms; excludes nonspecified supportive uses, hematopoietic stem cell transplantation-related uses, and uses unrelated to cancer or cancer-related symptoms.

    Policy Summary
    Payer1199SEIU National Benefit Fund
    PolicyOncology Medications Policy
    Policy CodePolicy N/A
    Change TypeInitial version
    Effective DateJune 15, 2021
    Next Review DateN/A
    Key ActionObtain prior authorization for nonexempt direct-treatment or specified supportive-treatment oncology medications and document the applicable NCCN-supported or FDA-indication medical-necessity standard.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    1, 2A, 2BRecognized NCCN evidence categories
    85%Primary regimens with NCCN support
    15%Primary approvals with NCCN exceptions
    95%Supportive medications with NCCN support

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    5%
    Supportive approvals with NCCN exceptions
    8Governed supportive medication classes

    Medical Necessity and Policy Scope

    Primary Treatment of Cancer

    Covered as medically necessary when ALL of the following criteria are met:

    ALL of the following

    • ONE of the following

      • The injectable, oral, or topical oncology medication is listed for a specific oncologic direct-treatment indication in the current National Comprehensive Cancer Network (NCCN®) Guidelines with a Category of Evidence and Consensus of 1, 2A, or 2B.
      • The FDA-approved medication is used for direct cancer treatment in accordance with its FDA indication and the indication is not currently addressed in the NCCN® Guidelines.
    • Prior authorization is obtained for the drug, unless the drug is listed in the policy's 'Prior Authorization NOT Required' Section 1a.

    Supportive Treatment of Cancer Patients

    Covered as medically necessary when ALL of the following criteria are met:

    ALL of the following

    • ONE of the following

      • The injectable, oral, or topical oncology medication is listed for a specific oncologic supportive-treatment indication in the current National Comprehensive Cancer Network (NCCN®) Guidelines with a Category of Evidence and Consensus of 1, 2A, or 2B.
      • The FDA-approved medication is used in accordance with its FDA indication as supportive care in cancer treatment and belongs to a governed class: hematopoietic growth factors, myeloprotective agents, erythroid maturation agents, fibroblast growth factor 23 inhibitors, antiemetic agents, bone-modifying agents, somatostatin analogues, or tryptophan hydroxylase inhibitors.
      • Bevacizumab is used for management of symptoms of radiation-induced necrosis.
    • Prior authorization is obtained for the drug, unless the drug is listed in the policy's 'Prior Authorization NOT Required' Section 2a.

    Exceptions to NCCN® Guidelines

    An exception to NCCN®-supported treatment may be medically necessary following individualized clinical review when ALL of the following apply:

    ALL of the following

    • ONE of the following treatment contexts

      • A medication regimen is requested for primary treatment of cancer and does not conform to NCCN® Guidelines because of a rare cancer, an unaddressed cancer subtype, or other individual patient or disease factors.
      • A medication regimen is requested for supportive treatment of cancer and does not conform to NCCN® Guidelines because of individual patient or disease factors.
    • The requested treatment is clinically appropriate based on individualized review.
    • The review may consider peer-reviewed scientific articles, clinical practice guidelines from professional or medical specialty societies, coverage policies of government or commercial payers, FDA indications, and clinical expertise from experienced board-certified oncology practitioners through real-time peer consultation.

    All other medication uses for the supportive treatment of cancer, beyond the governed supportive-treatment classes and uses specified in this policy, are outside the scope of this policy.

    All oncology medication uses related to hematopoietic stem cell transplantation—including, but not limited to, mobilization, harvest, transplantation, supportive care, and graft-versus-host disease—are outside the scope of this policy.

    Medication uses that are not associated with the direct treatment of cancer or the treatment of cancer-related symptoms are outside the scope of this policy.

    Authorization and Clinical Review Requirements

    Prior Authorization

    Direct Cancer Treatment Medications

    All injectable, oral, and topical medications used for a specific oncologic direct-treatment indication require prior authorization unless listed below as exempt. Direct-treatment medications are medically necessary when the indication is supported by NCCN Guidelines Categories of Evidence and Consensus 1, 2A, or 2B; FDA-approved medications not addressed by NCCN are medically necessary when used according to the FDA indication.

    • Prior authorization is not required for the following Section 1a exempted cancer-treatment medications: anastrozole; ethinyl estradiol; exemestane; letrozole; levonorgestrel; medroxyprogesterone; tamoxifen; toremifene; 6-mercaptopurine (oral formulation); 6-thioguanine (oral formulation); methotrexate (oral formulation); dexamethasone (oral and injectable formulations); hydrocortisone (oral and injectable formulations); methylprednisolone (injectable formulation); prednisolone (oral formulation); prednisone (oral formulation); celecoxib; diclofenac sodium; sulindac; doxycycline; ketoconazole; and doxazosin mesylate.
    • The Section 1a source also identifies sulindac under antimicrobials and ketoconazole under antihypertensives; the listed formulations and drugs remain subject to the exemption as specified in that section.
    Prior Authorization

    Supportive Medication Classes and Exemptions

    Policy Context

    This policy governs FDA-approved medications used either for the direct treatment of cancer or for specified supportive care. Supportive care therapies may prevent or treat clinical symptoms caused by primary cancer treatment medications or by the cancer itself. Uses outside direct cancer treatment, cancer-related symptoms, or the specified supportive medication classes are outside the policy scope.

    Policy Summary
    Payer1199SEIU National Benefit Fund
    PolicyOncology Medications Policy
    Policy CodePolicy N/A
    Change TypeInitial version
    Effective DateJune 15, 2021
    Next Review DateN/A
    Key ActionObtain prior authorization for nonexempt direct-treatment or specified supportive-treatment oncology medications and document the applicable NCCN-supported or FDA-indication medical-necessity standard.
    SourceLink
    On This Page
    Medical Necessity and Policy ScopeAuthorization and Clinical Review RequirementsPolicy Context

    FDA-approved medications used for supportive care in cancer treatment are governed by this policy when they fall within the specified supportive medication classes or the stated bevacizumab use. The listed supportive classes require prior authorization unless exempted in Section 2a.

    • Governed supportive classes are hematopoietic growth factors, myeloprotective agents, erythroid maturation agents, fibroblast growth factor 23 inhibitors, antiemetic agents, bone modifying agents, somatostatin analogues, and tryptophan hydroxylase inhibitors.
    • Bevacizumab used to manage radiation-induced necrosis symptoms is also governed by this policy.
    • Prior authorization is not required for Section 2a exempted supportive medications: generic granisetron (oral and injectable formulations); generic aprepitant (oral formulation); corticosteroids, benzodiazepines, phenothiazines, atypical and typical antipsychotics, cannabinoids, and anticholinergics (all drugs in class); metoclopramide; alendronate; and pamidronate.
    Note

    Use Outside Policy Scope

    Medication uses outside the specified direct-treatment and supportive-treatment scope are not governed by this policy. Providers should not apply this oncology medication policy to the excluded uses below.

    • All other medication uses for supportive treatment of cancer outside the specified supportive classes are outside the scope of this policy.
    • All oncology medication uses related to hematopoietic stem cell transplantation—including mobilization, harvest, transplant, supportive care, and graft-versus-host disease—are outside the scope of this policy.
    • Medication uses not associated with the direct treatment of cancer or cancer-related symptoms are outside the scope of this policy.
    Documentation Required

    Required Authorization or Medical-Necessity Support

    Submit prior authorization for covered oncology medication use unless the medication is expressly exempted in Section 1a or Section 2a. Medical-necessity support should establish either the applicable NCCN evidence standard or, when the use is not addressed by NCCN, compliance with the FDA indication.

    • For direct cancer treatment and specified supportive treatment, NCCN-listed injectable, oral, and topical oncology medications with Categories of Evidence and Consensus 1, 2A, or 2B are recognized as evidence-based standards of care and medically necessary.
    • FDA-approved direct-treatment medications not addressed in NCCN are recognized as medically necessary when used according to the FDA indication.
    • FDA-approved medications in the specified supportive classes not addressed in NCCN are recognized as medically necessary when used according to the FDA indication.
    • Prior authorization remains required for drugs in the applicable treatment or supportive categories unless the drug or class is listed as exempt in Section 1a or Section 2a.