CurrentColorado Rocky Mountain Health PlansPolicy N/A

Oral Oncology Agents Prior Authorization (Form-based Coverage Criteria)

Governance and prior authorization requirements for oral oncology (antineoplastic) medications submitted to Colorado Rocky Mountain Health Plans; applies to providers requesting new or continuation therapy for Medicaid recipients.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOral Oncology Agents Prior Authorization (Form-based Coverage Criteria)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with required medical records (diagnostic evaluations, recent chart notes, and most recent related labs); requests may be faxed to 1-866-940-7328 or submitted via the Pharmacy PA Call Center at 1-800-310-6826.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 yrmaximum authorization

5 yrsrecord retention

1-866-940-7328submission fax

1-800-310-6826PA call center

Coverage and Medical Necessity Criteria

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOral Oncology Agents Prior Authorization (Form-based Coverage Criteria)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Authorization criteria

Covered when ALL of the following are met

Form completion and documentation: Completed prior authorization form including patient and prescriber identifiers; medication requested with strength, directions, quantity; diagnosis selected; prior medication trials listed; concurrent medications listed; prescriber signature and date

An incomplete form may be returned

Required records: All copies of medical records (diagnostic evaluations and recent chart notes) and the most recent related labs are provided

Provider must retain documentation for five years

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for oral oncology agents. Submit requests using the payer's oral oncology agents form; incomplete forms may be returned or denied. Submission options: fax to 1-866-940-7328 or phone the Pharmacy PA Call Center at 1-800-310-6826.

Fax: 1-866-940-7328
Phone: 1-800-310-6826
Use the oral oncology agents PA form; complete all fields

Note

Provider Action Required

Complete the PA form fully and include prescriber and patient identifiers, medication details, diagnosis, prior medication trials, and prescriber's signature and date. Failure to complete required fields may delay processing or lead to denial.

Patient: name, Medicaid ID, DOB, height/weight/BSA
Prescriber: name, NPI, phone, fax, specialty, signature and date
Medication: name, strength, directions, quantity/month, # of cycles
Diagnosis and prior medication trials

Documentation Required

Required Documentation

Submit all supporting medical records with the request: diagnostic evaluations, recent chart notes, and the most recent related laboratory results. These documents are required for review.

Diagnostic evaluations and recent chart notes
Most recent relevant labs
List of concurrent medications

Denial Risk

Incomplete Forms and Record Retention

The provider must retain copies of all documentation for five years. If the form is incomplete or supporting documentation is missing, the request may be returned or denied and denial reasons will be documented.

Provider record retention: 5 years
Incomplete form or missing records can trigger return or denial

Policy Background and Purpose

This prior authorization form is used to request approval for oral oncology (antineoplastic) agents. It collects patient identifiers (Medicaid ID, name, date of birth), prescriber information (name, NPI, phone, fax, specialty), and clinical details about the request, including whether the request is new or a continuation, patient height/weight/BSA, the medication requested with strength, directions, number of cycles, and monthly quantity, the diagnosis (with selectable cancer types and an 'Other' free-text option), prior medication trials, and concurrent medications. The form requires the prescriber's signature and date and states that it must be completed in full; an incomplete form may be returned. It also specifies required documentation for review: all copies of medical records (e.g., diagnostic evaluations and recent chart notes) and the most recent related labs, and notes that the provider must retain documentation for five years. The form indicates a Maximum Approval = One Year.

OpenPayer

Oral Oncology Agents Prior Authorization (Form-based Coverage Criteria)

Coverage and Medical Necessity Criteria

Codes and Authorization Duration

Provider Requirements and Prior Authorization

Policy Background and Purpose

Definitions and Limits