Criteria for Prior Authorization — Oncology: Auxiliary Treatment Agents
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Defines prior authorization requirements and renewal criteria for a list of oncology auxiliary treatment agents for Kansas Medicaid members; applies to providers requesting coverage for the listed drugs and dose forms.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial approval criteria
Covered when ALL of the following are met for initial approval:
Renewal criteria
Renewal approval requires ALL of the following:
For drugs that already have a prior authorization requirement but for which a newly approved indication, dosage, or age change is not specifically listed in this policy, the PA request will be evaluated against the FDA package insert. Review will consider the indication, age, dose, and any prerequisite treatment requirements described in the package insert to determine medical necessity and applicability of coverage.
This policy lists multiple supportive and adjunctive oncology agents (examples include Luspatercept (Reblozyl®), Mesna (Mesnex®), Motixafortide (Aphexda®), and others). For the listed products, the documented package‑insert requirements will guide approval decisions when the PA pertains to a new indication, dose, or age group not already specified in the PA criteria.
Listed Agents and Coding
| Atgam | Anti-thymocyte globulin (Atgam®) |
| Aranesp | Darbepoetin alfa (Aranesp®) |
| Denosumab/Prolia/Xgeva | Denosumab (multiple brand names listed) |
| Elliotts B solution | chemotherapy diluent |
| Ryzneuta | Efbemalenograstim alfa-vuxw (Ryzneuta®) |
| Rolvedon | Eflapegrastim-xnst (Rolvedon®) |
| Epogen/Procrit/Retacrit | Epoetin alfa |
| Neupogen/Zarxio/etc. | Filgrastim (various brands) |
| Focinvez | Fosaprepitant (Focinvez™) |
| Akynzeo IV | Fosnetupitant/palonosetron (Akynzeo® IV) |
Provider Actions and Billing
Prior authorization required for listed agents (all dose forms)
Prior authorization is required for all current and future dose forms of the listed oncology auxiliary treatment agents. Initial approval also requires that the medication meets all package‑insert criteria (FDA‑approved indication, age, dose, and prerequisite treatments).
- PA applies to every dose form now and any dose forms introduced later.
- Initial approval: prescribed according to the FDA‑approved indication, age, dose, and prerequisite treatments in the package insert.
Use preferred PDL drug when available
When a preferred PDL drug treats the PA indication, that preferred agent must be used unless the patient meets the non‑preferred PDL PA criteria.
- If an applicable preferred PDL drug is available for the indication, non‑preferred agents require meeting non‑preferred PA criteria.
Prescriber attestation and package‑insert adherence for renewals
For renewal, the prescriber must attest that the patient has experienced a positive clinical response from continuous treatment and is able to tolerate therapy; the patient must continue to meet the criteria required for initial approval, which includes prescribing consistent with the package insert.
- Renewal requires prescriber attestation of clinical benefit and tolerability.
- Patient must continue to meet initial approval criteria (FDA‑approved indication, age, dose, prerequisite treatments).
Reference KMAP Reference Codes for billing/provider-type codes
For drug coverage and provider type billing code information, providers should reference the KMAP Reference Codes webpage.
- KMAP Reference Codes lists billing codes and provider type details relevant to these agents.
Denial risk if not prescribed per FDA‑label/package insert
A request may be denied if the medication is not prescribed according to the FDA‑approved indication, age, dose, and prerequisite treatments as stated in the package insert.
- Noncompliant prescribing relative to the package insert (indication, age, dose, prerequisites) is a denial risk.
Denial risk when a preferred PDL drug is available
Requests may be denied if a preferred PDL drug that treats the PA indication is available and the patient does not meet the non‑preferred PDL PA criteria.
- If an applicable preferred PDL agent exists for the indication, lack of meeting non‑preferred PA criteria is grounds for denial.
Background
This policy defines prior authorization requirements for a heterogeneous set of non‑chemotherapy supportive and adjunctive oncology agents (for example, growth factors, bone‑targeted agents, antiemetics, enzyme rescue agents, and other auxiliary treatments) that are used to prevent or manage complications of cancer therapy or the disease itself. Coverage decisions require that prescribing and dosing conform to the FDA‑approved indication and package insert prerequisites.
Initial approvals require that the medication be prescribed according to the FDA‑approved indication, age, dose, and any prerequisite treatments in the package insert, and that when a preferred PDL drug can treat the PA indication the preferred agent is used unless the patient meets non‑preferred PDL PA criteria. Renewal requires the prescriber to attest that the patient has experienced a positive clinical response and tolerates ongoing therapy, and that the patient continues to meet the initial approval criteria.
Prior authorization applies to all current and future dose forms of the listed oncology auxiliary agents and, unless specified otherwise, approvals are issued for 12 months. Providers should reference the KMAP Reference Codes webpage for billing and code guidance when submitting PA requests.
Definitions
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