CurrentColorado Rocky Mountain Health PlansPolicy N/A

Chemotherapy and Supportive Care Prior Authorization Form - Coverage Criteria

A standardized prior authorization request form for chemotherapy and supportive care drugs and services to be completed by providers; applies to members of Colorado Rocky Mountain Health Plans and their providers seeking authorization for cancer treatments, supportive agents, and exceptions to step therapy.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyChemotherapy and Supportive Care Prior Authorization Form - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed chemotherapy and supportive care prior authorization form (or use the health plan portal) with required attachments to request authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Sections I-VForm sections

RequiredAttachments

ExceptionsStep therapy

Coverage / Authorization Criteria

Information required to consider authorization

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Member and clinical data: Completed member demographics, diagnosis, tumor histology, ECOG score, stage, and comorbidities are provided

Fields appear throughout Sections I-III

Treatment details: Anti-cancer treatment request specifying regimen, route, frequency, cycles, billing method (buy-and-bill or pharmacy), and supportive care drugs with indication are provided

Section III and II capture these items

Provider and site information: Ordering and treating provider information, NPI, place of treatment, TIN, and site of service are completed

Section IV

Supporting documentation: Attachments including progress notes, chemotherapy orders, laboratory results, pathology, and imaging results are supplied to support medical necessity

Explicitly required on the form

Step therapy exception rationale: If step therapy applies, provide one or more justification: contraindication/adverse reaction, expected ineffectiveness due to clinical characteristics, prior trial failure or adverse event, or member stability on current therapy making switching harmful

Section V (Exceptions to Step Therapy) lists acceptable rationales

The form does not enumerate any standalone exclusions on its face. When completing or reviewing a request, providers and reviewers should rely on the member's specific benefit plan and the health plan's coverage policies to determine whether particular drugs, indications, or services are excluded. The form itself directs providers to consult the health plan's coverage policies and member benefits for applicability and does not replace those plan-level exclusions.

The prior authorization form does not list discrete Not Medically Necessary conditions. Instead, determinations about medical necessity depend on the clinical documentation supplied with the request and on the plan's medical necessity guidance. Reviewers may deny or delay authorization if submitted documentation does not demonstrate medical necessity consistent with the member's coverage policies.

Category	Selectable indications / fields
Bone strengthening / bone antiresorptive agents	Osteoporosis; Bone metastases (checkboxes shown on form)
Erythropoiesis-stimulating agents (ESAs)	Chronic kidney disease (CKD); Chemotherapy‑induced anemia (CIA); Adjuvant breast cancer; Myelodysplastic syndrome (MDS); Anemia of chronic disease (ACD) (checkboxes shown on form)
Planned anti-cancer regimen (provider-entered)	Fields to capture regimen name, frequency/schedule, line of treatment, prior therapies tried, whether patient is currently being treated with requested regimen, and site of service (outpatient hospital, home infusion, other)
Billing / site and administration details	Billing method (Buy-and-Bill or Pharmacy); place of treatment, treating/ordering provider NPI, TIN, site of service selection; attachments required (labs, imaging, chemo orders, pathology, progress notes)

Provider Submission & Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Submit a completed chemotherapy/supportive care prior authorization (PA) form or use the health plan's provider portal. Include the requested treatment start date, patient identifiers, ordering and treating provider details (names, NPIs, TIN, phone, fax), site of service, line of treatment, and whether the patient is currently receiving the requested regimen.

Use the plan portal in lieu of the paper form when available
Indicate if request is out-of-network and whether provider is the only available treating provider within a reasonable distance
Specify if treating provider is in-network

Denial Risk

Documentation and Step Therapy Justification Required

Documentation & Step Therapy Justification Required: Complete all applicable sections of the PA form, including the step therapy exceptions section when step therapy applies. Provide a clear clinical rationale if requesting an exception (e.g., contraindication, likely ineffectiveness, prior trial and failure, adverse reaction, or clinical stability that would be harmed by switching therapy). Failure to provide required justification and supporting documentation may result in denial or delay.

If step therapy applies, complete the exceptions section and state which exception criterion is met
Describe prior trials: drug name(s), dates/duration, reason for discontinuation (adverse reaction, inadequate response, diminished effect)
If claiming contraindication or likely harm, briefly describe clinical details and expected harm

Documentation Required

Required Attachments

Required Attachments: Attach supporting clinical documentation with the PA request to demonstrate medical necessity and substantiate any step therapy exception. Include the most recent and relevant clinical records.

Progress notes (office notes, treatment summaries)
Chemotherapy orders / regimen orders
Relevant laboratory results
Pathology reports (including tumor mutation/biomarker/genetic testing results)
Imaging reports and relevant images or summaries

Step Therapy

Step Therapy Exceptions Documentation

Step Therapy Exceptions Documentation: When requesting an exception to step therapy, complete the exceptions section and provide specific supporting details — e.g., documented contraindication or expected adverse reaction to the alternative agent; objective reasons the alternative is expected to be ineffective based on tumor or patient characteristics; prior trial details showing lack of efficacy or intolerance; or documentation that the patient is stable on the requested drug and switching would cause harm.

State which exception applies and attach corroborating records
Provide drug names, dates/duration of prior use, and nature of adverse reaction or inadequate response
If claiming stability, provide recent progress notes documenting stability and anticipated harm from switching

Form Purpose & Scope

This is a standardized clinical chemotherapy and supportive care prior authorization form that collects core information needed to evaluate requests: member demographics and benefit details, diagnosis and tumor histology, ECOG/performance status, line of therapy (new, re-authorization, retrospective, prior therapies tried), the requested anti-cancer regimen or supportive care agents (including indications for bone antiresorptives and erythropoiesis‑stimulating agents), and ordering/treating provider and site-of-care information. The form also requires attachments such as progress notes, chemotherapy orders, laboratory results, pathology, and imaging to support medical necessity and any step therapy exception rationale.

Key Fields & Definitions

Supportive care drugs — examples and indicated uses

Bone antiresorptive/strengthening agentsIndications selectable on the form: Osteoporosis; Bone metastases

Erythropoiesis-stimulating agents (ESAs)Indications selectable on the form: Chronic kidney disease (CKD); Chemotherapy-induced anemia (CIA); Adjuvant breast cancer; Myelodysplastic syndromes (MDS); Anemia of chronic disease (ACD)

Billing/administration fieldsForm captures administrative drug name and billing method for supportive agents

Line of Treatment

Request type / Line of TreatmentForm includes a 'Line of Treatment' field to indicate New, Re-Authorization, Retrospective, or other line (first-line, second-line, salvage)

Prior therapies triedForm asks 'What therapies has the patient previously tried?' to document prior systemic or local treatments

Current treatment statusForm asks whether the patient is currently being treated with the requested regimen(s) (Yes/No/Unknown)

Specified Line of Therapy

Line of Therapy (first-line | second-line | salvage)

Line of therapy capture: Provider must indicate whether the request is New (first-line), Re-Authorization, Retrospective, and document prior therapies tried (select first-line, second-line, or salvage as applicable)

Line of Treatment field in Section IV

Tumor Biomarkers & Genetic Testing

Tumor mutations / biomarkers / genetic testing

Screening for tumor mutations/biomarkers/genetic testingForm asks: 'Has the patient been screened for tumor mutations/biomarkers/genetic testing?' (Yes/No/Unknown)

Test results captureIf screened, the form requests the specific tumor mutations/biomarkers/genetic testing results that the patient has been tested for

Use for therapy selectionBiomarker/testing information is requested when relevant to therapy selection to support medical necessity and regimen choice