CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Oncology-Hematology Medication Policy

Defines coverage, review, and authorization processes for oncology and hematology medications for Neighborhood Health Plan of Rhode Island members (Medicaid, Commercial, and Medicare where applicable) focusing on medically administered drugs; retail pharmacy formulary for some lines is managed by the PBM.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOncology-Hematology Medication Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective Date09/01/2020

Next Review DateN/A

Key ActionObtain plan authorization for medically administered oncology and hematology medications; New Century Health has delegated review authority.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

09/01/2020policy effective date

Medicaid, Commercial, Medicarelines of business

New Century Healthdelegated review

Multiple datesreview history

Coverage Criteria

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOncology-Hematology Medication Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective Date09/01/2020

Next Review DateN/A

Key ActionObtain plan authorization for medically administered oncology and hematology medications; New Century Health has delegated review authority.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

General coverage conditions: Medication is an oncology or hematology agent within scope for Medicaid and for medically administered drugs in MMP and Commercial, AND the requested indication is supported by recognized compendia or CMS determinations (e.g., NCD/LCD, NCCN, AHFS, Clinical Pharmacology, Micromedex DrugDex, Lexi-Drugs), AND authorization is obtained when required (for example, when an unclassified HCPCS code is used).

Review and approval authority may be delegated to New Century Health; retail pharmacy formulary decisions for MMP and Commercial are managed by Neighborhood's PBM.

Provider Actions & Authorization

Prior Authorization

Prior Authorization Required

Medically administered oncology and hematology medications within scope require prior authorization. New Century Health is delegated to review these medications and has approval authority; potentially adverse determinations remain the responsibility of Neighborhood Health Plan of Rhode Island.

Applies to Medicaid medically administered drugs and MMP/Commercial medically administered drugs (effective 2020-09-01).
See Oncology/Hematology Medical Policies on the Clinical Medical Policies webpage and Oncology/Hematology Medicaid Pharmacy Benefit Policies on the Medicaid Pharmacy Criteria webpage.

Step Therapy

Biosimilar / Agent Selection

Neighborhood may require use of a biosimilar when one is available, or adjust reimbursement rates where multiple agents exist. Providers should anticipate substitution or rate adjustment requests and document clinical rationale when requesting a non-preferred biologic.

Biosimilar substitution or rate adjustment may be applied at plan discretion.
Documented clinical justification may be required to request a reference biologic instead of a biosimilar.

Billing Rule

Unclassified HCPCS Authorization

Medications that lack a specific HCPCS code and are billed with an unclassified HCPCS code require plan authorization for payment. Ensure authorization is obtained and include supporting documentation referencing applicable compendia or policy guidance.

Obtain plan authorization prior to billing unclassified HCPCS (e.g., J9999-type) for oncology/hematology agents.
Include clinical documentation and cite applicable reference compendia or existing oncology/hematology policy during authorization request.

Documentation Required

Authorization and Documentation Notes

Authorization requests and documentation should reference accepted clinical compendia when no specific oncology/hematology policy exists. Acceptable references include NCCN, AHFS, Clinical Pharmacology, Micromedex DrugDex, and Lexi-Drugs.

Cite one or more of the following: NCCN, AHFS, Clinical Pharmacology, Micromedex DrugDex, Wolters Kluwer Clinical Drug Information Lexi-Drugs.
Per §§ 42 CFR 422.101, Medicare members are subject to NCD/LCD when present; this policy applies to Medicare only in absence of NCD/LCD.

Background

This policy covers oncology and hematology medications that are medically administered and, where specified, pharmacy-dispensed for Medicaid. Medically administered oncology and hematology medications in scope require authorization by the plan, with New Century Health delegated to conduct reviews and exercise approval authority on Neighborhood’s behalf.

When a specific oncology/hematology policy is not available for an agent, the medication and indication will be evaluated against recognized compendia and coverage determinations — including NCDs/LCDs, NCCN, AHFS, Clinical Pharmacology, Micromedex DrugDex, and Lexi-Drugs — to determine whether the use is medically accepted.

Note that medications that lack a specific HCPCS code and require an unclassified HCPCS code require authorization from the plan for payment. Additionally, Neighborhood may mandate use of a biosimilar or apply rate adjustments when multiple equivalent agents exist.

Definitions

Medically administered drugs — definition

DefinitionMedically administered drugs

ScopeApplies to medically administered oncology and hematology medications for Medicaid and for MMP and Commercial members (medically administered only).

Retail pharmacy noteRetail pharmacy formulary management for MMP and Commercial is handled by Neighborhood's PBM (this policy does not govern those retail formulary decisions).

Authorization requirementMedications without a specific HCPCS code that require use of an unclassified HCPCS code require authorization from the plan for payment.

Biosimilar preferenceNeighborhood may require use of a biosimilar or adjust rates when multiple agents are available.

Medicare applicabilityApplies to Medicare only in the absence of an NCD or LCD per 42 CFR 422.101.

OpenPayer

Oncology-Hematology Medication Policy

Coverage Criteria

Coding

Provider Actions & Authorization

Background

Definitions

Step Therapy / Agent Selection

Site of Care

Biosimilar Policy