CurrentColorado Rocky Mountain Health PlansPolicy N/A

Oral Oncology (Florida) Prior Authorization Form - Community Planopen_in_new

Form and instructions to request prior authorization for oral oncology agents (maximum approval one year) for Colorado Rocky Mountain Health Plans Community Plan (Florida). Specifies required patient/prescriber information, diagnosis, prior medication trials, concurrent medications, and supporting documentation required for review.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOral Oncology (Florida) Prior Authorization Form - Community Planopen_in_new

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionFax the completed form to 1-866-940-7328 or contact Pharmacy PA Call Center at 1-800-310-6826 to request prior authorization for oral oncology agents; form must be fully completed for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes reported for this update.

1 yearMaximum Approval Duration

5 yearsDocumentation Retention

Coverage Summary

This form and instructions request prior authorization for oral oncology (antineoplastic) agents for Colorado Rocky Mountain Health Plans Community Plan (Florida). It is used by the payer to review and authorize treatment, and the coverage stance is covered_with_criteria with a maximum approval of one year. The form must be completed in full and includes fields to document approval/denial, start and expiration dates for the authorization.

Prior Authorization Submission & Approval Criteria

Prior Authorization Submission Requirements

Form must be completed in full. Approval limited to one year. Review requires ALL of the following:

ALL of the following

Completed prior authorization form including date, prescriber notified/approved/denied fields, start and expiration dates
Patient identifiers: Recipient's Medicaid ID#, Date of Birth, Recipient's Full Name
Prescriber information: Full Name, NPI, Phone Number, Fax Number, Provider Specialty
Medication request details: New or Continuation; Medication name; Strength; Directions; Number of Cycles; Quantity/Month
Patient anthropometrics: Height (in/cm), Weight (lb/kg), Body Surface Area (BSA)
Diagnosis selection: at least one diagnosis (Breast Cancer, Renal Cancer, Prostate Cancer, Lung Cancer, Ovarian Cancer, Leukemia, or Other with specification)
Previous medication trials: medication name, strength, directions, start/end dates, maximum dose per day
Concurrent medications: list all other medications the patient is taking concurrently with the antineoplastic
Prescriber's signature and date
Required supporting documentation: copies of medical records (diagnostic evaluations, recent chart notes) and most recent related labs
Provider retention: Provider must retain copies of all documentation for five years

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Prior Authorization Submission Requirements

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Approval Characteristics

Conditions of approval:

ALL of the following

Maximum approval period is one year (start date and expiration date to be recorded on form)
Record START DATE and EXPIRATION DATE on the form

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Approval Characteristics

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Provider Actions & Requirements

Prior Authorization

Submit completed PA form

Fax the completed form to 1-866-940-7328 or contact the Pharmacy PA Call Center at 1-800-310-6826 to request prior authorization for oral oncology agents. The form must be fully completed for review.

Documentation Required

Attach supporting medical records and labs

Include copies of diagnostic evaluations, recent chart notes, and the most recent related labs with the submission. The provider must retain copies of all documentation for five years.

Billing Rule

Approval period recording

If approved, record the START DATE and EXPIRATION DATE on the form. Maximum approval period is one year.

Denial Risk

Incomplete form may be returned

An incomplete form may be returned, which may delay review or result in denial of the request.

Background

This document is a prior authorization request form for oral oncology (antineoplastic) agents. It captures patient identifiers (Recipient's Medicaid ID#, Date of Birth, Full Name), prescriber information (Full Name, NPI, Phone, Fax, Provider Specialty), and medication request details (new or continuation, medication name, strength, directions, number of cycles, quantity per month). It also records patient anthropometrics (height, weight, BSA), diagnosis selection (Breast, Renal, Prostate, Lung, Ovarian, Leukemia, or Other), previous medication trials (medication, strength, directions, start/end dates, maximum dose per day), and concurrent medications. The form requires the prescriber's signature and date, and specifies required supporting documentation (copies of medical records such as diagnostic evaluations and recent chart notes, and the most recent related labs) to support utilization review; providers must retain documentation for five years. Fax submission instructions and the Pharmacy PA Call Center number are provided to request prior authorization.