Currentpriority healthPolicy N/A

Medical prior authorization for oncology drugs

Form and criteria governing prior authorization requests for oncology medications for Priority Health commercial members; applies to providers requesting new or continuation drug coverage and documents required for review.

Policy Summary

Payerpriority health

PolicyMedical prior authorization for oncology drugs

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with patient demographics, provider information, dosing details, ECOG performance status, chart notes and required documentation to support initial or continuation approval.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsmax approval duration

0-2required ECOG

2 articlesoff-label evidence

Faxsubmission method

Coverage Criteria

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Initial Approval Criteria: 1. Patient has an FDA‑approved indication for the requested drug OR use is consistent with NCCN category 1 or 2A recommendations for the cancer type, stage, line of therapy, and performance status. Consideration for uses that do not meet these criteria requires submission of two peer‑reviewed medical journal articles.; 2. Coverage of NCCN category 2B recommendations will be considered only after failure of category 1 or 2A recommendations or when higher recommendations are not indicated.; 3. Drug is prescribed by an oncologist, hematologist, or other board‑certified prescriber qualified to treat the specified cancer type.; 4. Appropriate genetic testing results are provided as required by FDA‑approved labeling and NCCN guidelines to support the requested use.; 5. Patient has an ECOG performance status score of 0–2.; 6. Any additional drug‑specific prior authorization criteria listed on Priority Health's website are met. When these criteria are satisfied, initial approval will be granted for no more than 12 months.

Supporting documentation required

inv-02: Continuation Therapy

For continuation, patient must meet ALL of the following requirements:

Continuation Approval Criteria: 1. Current chart notes documenting clinical response and compliance with therapy are provided.; 2. Documentation of clinical outcomes is submitted to Priority Health.; 3. Coverage may be discontinued for noncompliance with medical or pharmacologic therapy or for disease progression after initiation of therapy. When these continuation criteria are met, approval will be for no more than 12 months.

Continuation requires objective documentation

Indications, dosing, or routes of administration that are not supported by the FDA or by CMS-accepted compendia require documentation from the provider. Specifically, the request must be accompanied by two published peer-reviewed medical journal articles that support the appropriateness of the drug, the proposed dosing, or the proposed route of administration for the identified indication. If these two articles are not provided, the request is not supported for coverage.

Coverage may be discontinued when there is evidence the drug is no longer providing benefit or when the member is not following prescribed therapy. Specifically, coverage may be discontinued for disease progression after initiation of drug therapy or if the patient is noncompliant with medical or pharmacologic therapy. Continuation requests must include current chart notes documenting response and compliance; when continuation criteria are met, approvals are granted for up to 12 months.

Initial Therapy Criteria

inv-15: Initial Therapy

Initial coverage requires FDA‑approved indication or NCCN category 1/2A; genetic testing and ECOG 0–2 are required. Approvals are granted up to 12 months when criteria are met.

Initial Oncology Drug Criteria (NCCN/FDA based): 1. FDA‑approved indication or use consistent with NCCN category 1 or 2A for the specific cancer type, stage, line of therapy, and performance status.; 2. Prescribed by an appropriate board‑certified specialist (oncologist, hematologist, or equivalent).; 3. Required genetic testing results per FDA labeling and NCCN guidelines are submitted.; 4. ECOG performance status documented and between 0 and 2.; 5. Any additional drug‑specific PA criteria on Priority Health's website are satisfied. Initial approvals are limited to a maximum of 12 months.ECOG 0-2

Genetic testing and supporting documentation required

Continuation Therapy Criteria

inv-16: Continuation Therapy

Continuation approvals require documentation of clinical response and compliance; approvals are granted up to 12 months and may be discontinued for progression or noncompliance.

Continuation Requirements: 1. Provide current chart notes demonstrating clinical response to the medication and patient adherence to the prescribed regimen.; 2. Submit documentation of clinical outcomes as part of the continuation request.; 3. Coverage may be discontinued if the patient is noncompliant with therapy or if disease progression has occurred since initiation of drug therapy. When continuation criteria are met, approval will be granted for no more than 12 months.

Continuation approvals require objective documentation of response and compliance

Provider Actions & Requirements

Documentation Required

Required documentation

Submit a completed prior authorization form with patient demographics, provider information, dosing details, place of administration, ICD-10 and HCPCS/CPT codes. Include clinical documentation (chart notes, lab results, ECOG performance status, genetic testing) supporting the requested use.

Completed PA form with patient name, ID, DOB, PCP, requesting physician, NPI, contact, signature
Patient dosing information: last dose date, next dose date, total doses/cycles/duration, height, weight, BSA, dose and frequency
Include ICD-10 diagnosis code(s) and HCPCS/CPT code(s) for drug and administration
Attach relevant chart notes and lab records (including genetic testing)

Prior Authorization

Initial authorization requirements

Initial approval requires documentation that the indication is FDA-approved or consistent with NCCN category 1 or 2A recommendations for the cancer type, stage, line of therapy, and performance status. If not meeting those criteria, submit two peer-reviewed medical journal articles supporting the use. Prescriber must be an oncologist, hematologist, or other board-certified provider qualified to treat the cancer. Additional drug-specific PA form criteria apply. Initial approvals are granted for up to 12 months.

Must meet FDA indication OR NCCN category 1 or 2A for the specific cancer type/stage/line of therapy
If not FDA/NCCN 1/2A: provide two peer-reviewed journal articles supporting the use
Prescriber must be appropriately board-certified (oncology/hematology or equivalent)
ECOG performance status must be 0–2
Initial approval duration: up to 12 months

Prior Authorization

Continuation authorization requirements

For continuation/renewal, provide current chart notes documenting clinical response and compliance with therapy. Coverage may be discontinued for noncompliance or disease progression. Continuation approvals are granted for up to 12 months. For indications, dosing, or routes not FDA-approved or in CMS-accepted compendia, submit two peer-reviewed articles to support continued use.

Submit recent chart notes showing response to therapy and adherence
Document whether patient is compliant and whether disease has progressed
Authorization may be discontinued for noncompliance or progression
Continuation approval duration: up to 12 months
If off-label or not in compendia: provide two peer-reviewed articles

Step Therapy

NCCN-based sequencing

NCCN category 2B recommendations may be considered only after failure of category 1 or 2A recommendations or when higher-level recommendations are not appropriate; indicate prior therapies tried and dates. Provide rationale and supporting documentation when requesting coverage under NCCN 2B.

Select NCCN category (1, 2A, or 2B) on PA form
For 2B requests: document prior failure of category 1/2A therapies or reason why higher recommendations are not appropriate
List previous therapies with dates (chemotherapy, immunotherapy, targeted therapy, transplant)

Denial Risk

Triggers for denial

Coverage may be denied if the patient does not have an FDA-approved indication or NCCN category 1 or 2A support (or appropriate supporting evidence). Ensure all required documentation is submitted to avoid delays or denial.

Denial triggers: lack of FDA indication and no NCCN 1/2A support or insufficient supporting literature
Incomplete documentation (missing chart notes, labs, ECOG, genetic testing) may result in denial

Coding

Billing codes to be suppliedmixed

ICD-10	ICD-10 Diagnosis Code(s) (to be provided on form)
HCPCS	HCPCS Code (to be provided on form)

ECOG performance status required — 0-2

Required ECOG for initial approvalEastern Cooperative Oncology Group (ECOG) performance status score between 0 and 2 is required for initial authorization.

Source guidanceECOG must be documented as part of supporting documentation for initial coverage determinations.

Related continuation ruleContinuation requests must include current chart notes documenting response and compliance; ECOG documentation may be required for ongoing review.

Site of Care / Place of Administration

Note

Place of administration must be specified (self, office, infusion facility, or home)

Indicate the place of administration on the request: patient self‑administration, physician office, outpatient infusion facility (include facility name and NPI), or home infusion agency (include agency name and NPI).

Patient self‑administration
Physician office
Outpatient infusion facility — include NPI
Home infusion agency — include NPI

Definitions

NCCN categories (as used in this form)

Preferred categories for coverageNCCN guideline category 1 or 2A recommendations are required/preferred for initial coverage.

Consideration of category 2BNCCN category 2B recommendations may be considered only after failure of category 1 or 2A recommendations or when higher recommendations are not indicated.

Evidence for non‑NCCN/FDA usesUses not meeting category 1/2A require submission of two peer‑reviewed medical journal articles to support coverage.

ECOG — Eastern Cooperative Oncology Group (ECOG) performance status scale where 0–2 is required for initial approval

ECOG scale requirementEastern Cooperative Oncology Group (ECOG) performance status scale — score of 0–2 is required for initial approval.

ECOG score options documented on formForm lists ECOG options: 0 (fully active), 1 (restricted in heavy activity), 2 (ambulatory, capable of self‑care), >3 (limited self‑care or disabled); other measures (e.g., Karnofsky) may be provided.

Documentation expectationECOG performance status must be provided on the precertification form and included in supporting chart notes and records submitted with the request.

Background

This prior authorization form is focused on oncology medications and aligns coverage with FDA approvals and NCCN guideline recommendations. It requires that prescribing be performed by an oncologist, hematologist, or other appropriately board-certified prescriber, and that genetic testing be provided per FDA labeling and NCCN guidance when applicable. An ECOG performance status of 0–2 is required for initial approval, and initial or continuation approvals are generally issued for up to 12 months when criteria are met.