Oncology treatment regimen review via Eviti Connect
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Defines prior authorization and review requirements for oncology treatment regimens submitted through the NantHealth Eviti Connect portal and applies to oncology drug regimens covered under the pharmacy/oncology benefit for CareSource members in Arkansas PASSE.
No material clinical or coverage changes in this revision.
Coverage Criteria for Oncology Regimens
inv-01: Initial Therapy
Covered when ALL of the following are met for initial authorization:
Regimen-level review includes supportive care medications and is performed via Eviti Connect.
inv-02: Continuation Therapy
Reauthorization covered when ALL of the following are met:
Scenarios not meeting these requirements may be considered on a case-by-case basis with timely supporting literature from nationally recognized peer-reviewed journals.
Requests for treatment under this regimen review policy that are intended for experimental or investigational purposes or for participation in a clinical trial are excluded from authorization. This aligns with the requirement that initial authorizations must meet established evidence standards and explicitly states that uses classified as experimental/investigational or trial-related will not be approved under the regimen review process.
Initial Authorization Requirements
inv-10: Initial authorization
Initial therapy requirements
Regimen-level review via Eviti Connect; Eviti-issued regimen codes and resulting authorization information are forwarded to the payer.
Reauthorization / Continuation Requirements
inv-11: Reauthorization
Reauthorization requirements
Exceptions may be considered on a case-by-case basis if timely clinical literature from nationally recognized peer‑reviewed journals is submitted.
Provider Submission and Documentation Requirements
Eviti Connect submission required
All oncology treatment regimens must be submitted to Eviti Connect for review via the NantHealth Eviti Connect portal. Eviti-issued regimen codes and resulting authorization information will be forwarded to CareSource. Eviti Connect review covers the regimen in its entirety, including supportive care medications and drugs that might otherwise not require PA.
- Eviti Connect submission required for all oncology regimens
- Eviti-issued regimen codes communicated to CareSource
Preferred regimen required prior to non-preferred
If a comparable preferred regimen (including a biosimilar or another agent in the same mechanistic class with similar efficacy and safety) is available, the member must try the preferred regimen first and show a lack of response, intolerance, or contraindication before a non-preferred/non-formulary drug will be authorized. This step requirement applies to initial requests for non-preferred agents used within an oncology regimen.
- Step therapy required prior to approval of non-preferred/non-formulary oncology drugs
- Exceptions allowed for intolerance or contraindication documented in the chart
Required documentation
Provide medical records, applicable lab results, genetic testing results (when relevant), and chart notes documenting diagnosis, baseline information, and all prior cancer treatments. Dose must not exceed FDA-labeled maximums or limits supported by compendia/guidelines. Requests for initial authorization must include documentation that the prescribing clinician is an oncologist or hematologist.
- Required: medical records, labs, genetic testing, and chart notes of prior treatments
- Dose must be within FDA labeling or compendia-supported limits
- Prescriber must be an oncologist or hematologist
Potential triggers for denial
Requests lacking adequate supporting evidence (FDA approval, NCCN category 1/2a/2b, or other Eviti-supported evidence), insufficient documentation, use outside accepted evidence-based categories, or regimen use for experimental purposes/clinical trial will be at high risk for denial. Non-preferred drug requests without documented trial and failure of a preferred alternative (or intolerance/contraindication) may be denied.
- Potential denial triggers: insufficient clinical evidence or documentation
- Use not supported by FDA/NCCN/Eviti evidence categories
- Non-preferred requests without documented trial/failure of preferred regimen
BIOSIMILAR — use preferred comparable drug when available
When a biosimilar or other comparable preferred agent exists, the preferred product must be used in the regimen unless the member has documented intolerance or contraindication. Reviewers will determine whether a biosimilar or same-class alternative is sufficiently comparable to require use prior to authorizing a non-preferred agent.
- Biosimilar or same-class preferred drugs must be used when available
- Document intolerance or contraindication to consider non-preferred agent
Step Therapy / Prior Preferred Regimen Requirements
| Step | Requirement | Failure criteria |
|---|---|---|
| 1 | Trial of a comparable preferred regimen (e.g., a biosimilar or a drug in the same mechanistic class with similar efficacy/safety) is required before authorization of a non-preferred/non-formulary drug unless the preferred regimen is not tolerated or is contraindicated. | Lack of response to the preferred comparable regimen |
Site of Care Notes
Eviti Connect manages regimen review and site‑of‑care labeling
Oncology regimens are managed via Eviti Connect; benefit labeling designates Oncology Regimens = Medical (Arkansas PASSE) and the Eviti review issues an Eviti code to indicate the regimen met evidence‑based standards and that an authorization has been forwarded to CareSource (the Eviti code is not a guarantee of payment).
Key Definitions
Background
Eviti Connect performs an evidence-based validation of oncology treatment plans at the regimen level, including supportive care medications. The review confirms that the proposed regimen meets one or more accepted evidence sources—FDA-approved indications, NCCN evidence categories 1/2a/2b, or recommendations in the Eviti evidence library (for example, nationally recognized peer-reviewed journals or professional society guidelines)—and that dosing and documentation requirements are met. An Eviti-issued regimen code indicates the review was completed and that authorization information has been forwarded to CareSource; however, the code does not guarantee payment.
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