Currentsierra health and lifePolicy N/A

Oncology Step Therapy Exception Prior Authorization Form

Form and instructions for providers to request an exception to oncology step therapy requirements for Sierra Health and Life members, limited to stage 3 or stage 4 cancer patients; used by ordering or rendering providers to request prior authorization or expedited review.

Policy Summary

Payersierra health and life

PolicyOncology Step Therapy Exception Prior Authorization Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit step therapy exception requests via the web portal (attach this form) or by fax to 1-800-282-8845 with supporting documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

stage 3–4cancer stages eligible for step therapy exception

8am-5pm MSTcoverage review team phone hours

1-800-282-8845fax number to submit form

2026SHL Provider Summary Guide referenced year

Oncology Step Therapy Exception Coverage Criteria

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Oncology Step Therapy Exception approval criteria

Covered with criteria when ALL of the following are met

Member stage requirement: Member has stage 3 or stage 4 cancerstage 3 or 4

Required eligibility for oncology step therapy exception

Submission and urgency requirement: Prior authorization or step-therapy exception request submitted via web portal (attach this form) or by fax to 1-800-282-8845; urgent/expedited requests must include provider certification that standard timelines may seriously jeopardize the enrolleeN/A

Follow indicated submission channels and mark urgency when clinically necessary

Documentation requirement: Submit progress notes, laboratory results, radiology results, previous medications, and other factors impacting the plan of careN/A

Incomplete documentation may delay processing; requests are reviewed by RNs, Pharmacists, and Board Certified Oncologists

Acceptable clinical rationale for exception (at least one must apply)

Alternative drugs contraindicated or tried with adverse outcome: Alternative drug(s) are contraindicated or were previously tried with adverse outcome (e.g., toxicity, allergy, or therapeutic failure). Provider must specify drugs, adverse outcome for each, and length of therapy if therapeutic failure.N/A
Document drugs tried, adverse events, and duration of therapy
Patient stable on current therapy: Patient is stable on the current drug(s) and there is high risk of significant adverse clinical outcome if medication is changed.N/A
Specify the anticipated significant adverse clinical outcome
Medical need for different or higher dosage: Medical need for a different dosage and/or higher dosage of the requested drug exists.N/A

Step therapy exception requests under this form are limited to members with stage 3 or stage 4 cancer. Requests for members with other cancer stages fall outside this exception pathway and should follow standard prior authorization processes.

Exception requests must include clinical justification relevant to advanced-stage disease (for example, prior contraindication or intolerance to formulary alternatives, therapeutic failure with alternatives, stability on a non-formulary agent with high risk from changing therapy, or medical need for a different or higher dosage). The form captures prior therapies, reasons for discontinuation, durations, and other rationale to support the exception.

Submission, Documentation, and Urgency Requirements

Prior Authorization

How to submit prior auth or exception requests

Prior authorization or step-therapy exception requests must be submitted electronically by attaching this form to a request in the web portal or sent via facsimile to 1-800-282-8845. Urgent/expedited requests require provider certification that applying the standard review timeline may seriously jeopardize the life or health of the enrollee.

Step Therapy

Eligibility and required rationale for oncology step therapy exceptions

Step therapy exception requests are limited to members with stage 3 or stage 4 cancer and must include a clinical rationale such as prior contraindication or adverse outcome to alternatives, therapeutic failure with alternatives, patient stability on current drug with high risk from change, medical need for different/higher dosage, or formulary/preferred drugs contraindicated or tried and failed.

Document which alternative drugs were tried or contraindicated and any adverse outcomes or lengths of therapy.
If claiming stability on current therapy, describe the anticipated significant adverse clinical outcome if changed.
If requesting dose exceptions, list dosages tried and medical reason for higher/different dosage.

Documentation Required

Required supporting documentation

Exception requests must include supporting medical documentation such as progress notes, laboratory results, radiology results, and records of previous medications to demonstrate medical necessity and the clinical basis for the exception.

Progress notes summarizing current clinical status
Relevant laboratory results
Relevant radiology reports/images
Medication history including dates, dosages, reasons for discontinuation, and adverse events

Denial Risk

Insufficient documentation may delay or cause denial

Processing delays or denials may occur if appropriate documentation of medical necessity is not provided with the request (for example: progress notes, lab results, radiology results, or prior medication records).

Ensure all requested clinical records are attached at time of submission to avoid delays.
Requests are reviewed by Registered Nurses, Pharmacists, and Board Certified Oncologists — incomplete records may prevent timely clinical review.

Key Definitions

inv-09: Exception to step therapy for oncology medications for members with stage 3 or stage 4 cancer — definition of step therapy exception

DefinitionException to step therapy for oncology medications for members with stage 3 or stage 4 cancer — an exception pathway that permits coverage consideration when the member has stage 3 or stage 4 cancer and the provider submits required clinical rationale and documentation.

Eligibility (most actionable)Member has stage 3 or stage 4 cancer — requests for other cancer stages are outside this exception pathway.

Required rationale examplesAt least one of: alternatives contraindicated or tried with adverse outcome; patient stable on current drug with high risk from change; medical need for different or higher dosage; formulary/preferred drugs contraindicated, tried and failed.

Required supporting documentationProgress notes, laboratory results, radiology results, previous medications, and other factors impacting the plan of care must be submitted.

Review teamRequests are reviewed by Registered Nurses, Pharmacists, and Board Certified Oncologists.

Submission routes and urgencySubmit via the web portal (attach this form) or by fax to 1-800-282-8845; urgent/expedited requests require provider certification that standard timelines may seriously jeopardize the enrollee.

Background

This form is intended to support clinical decision-making when requesting an exception to oncology step therapy requirements for Sierra Health and Life members with advanced-stage cancer. It standardizes the information reviewers need — including progress notes, laboratory results, radiology results, prior medications, and other factors impacting the plan of care — to evaluate medical necessity.

Providers must submit the completed form either electronically by attaching it to a web-portal prior authorization or step-therapy exception request, or by fax to 1-800-282-8845. Requests are reviewed by Registered Nurses, Pharmacists, and Board Certified Oncologists; insufficient documentation may delay processing.

Latest ICD-10 Code	Placeholder field for the most recent ICD-10 diagnosis code (entered by provider)
HCPCS/CPT/CDT Code	Placeholder field for HCPCS/CPT/CDT code(s) related to requested service

OpenPayer

Oncology Step Therapy Exception Prior Authorization Form

Oncology Step Therapy Exception Coverage Criteria

Requested Codes and Form Fields

Submission, Documentation, and Urgency Requirements

Key Definitions

Background