Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsUtah Health Plans Antineoplastic Coverage | OpenPa…
    Ask Trek AI about this page
    CurrentUniversity of Utah Health PlansPolicy PHARM-M017

    Antineoplastics - Medical Infused Drugs

    Customize your policy alerts

    Sign up for universityofutahhealthplans Policy PHARM-M017 alerts

    Get alerted when Policy PHARM-M017 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Commercial coverage and prior authorization for antineoplastic agents administered as medical infusions for members with an appropriate cancer diagnosis.

    Policy Summary
    PayerUniversity of Utah Health Plans
    PolicyAntineoplastics - Medical Infused Drugs
    Policy CodePolicy PHARM-M017
    Change TypeNo material change
    Effective DateJun 1, 2025
    Last ReviewMay 27, 2025
    Next Review DateMay 27, 2026
    Key ActionSubmit prior authorization requests through an oncologist and document a qualifying NCCN category 1, 2A, or 2B treatment option.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Prior authCoverage pathway
    1, 2A, 2BQualifying NCCN category
    12 monthsInitial authorization
    12 monthsRe-authorization
    Investigational

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Explicit exclusion

    Coverage Criteria and Exclusions

    Initial Therapy Criteria

    Antineoplastic agents may be considered medically necessary for treatment of a cancer diagnosis when ALL of the following are met:

    Initial therapy requirements

    • Requesting provider

      • The request must be made by an oncologist.

    • NCCN treatment category

      • The requested therapy is listed as an NCCN category 1 option for treatment.Category 1
      • The requested therapy is listed as an NCCN category 2A option for treatment.Category 2A
      • The requested therapy is listed as an NCCN category 2B option for treatment.Category 2B

    • Medical necessity

      • The requested therapy meets the medical-necessity criteria in PHARM-056, Prior Authorization and Medical Necessity.

    Continuation Therapy Criteria

    Continuation coverage requires ALL of the following:

    Continuation therapy requirements

    • Updated documentation

      • Updated clinical documentation must be submitted indicating compliance with and response to therapy.

    • Clinical response

      • The disease or condition has clinically improved.Improvement
      • The disease has stabilized.Stabilization

    Exclusions

    Coverage is excluded when ANY of the following applies:

    Exclusions and contraindications

    • The member has a contraindication to the requested therapy.
    • The request is for experimental or investigational use.
    • The member is noncompliant with prior medical or pharmacological therapy.

      Noncompliance may result in denial of coverage.

    Coverage is excluded when the member has a contraindication to the requested therapy.

    Coverage is excluded when the request is for experimental or investigational use.

    Noncompliance with prior medical or pharmacological therapy may result in denial of coverage.

    Prior Authorization and Provider Requirements

    Prior Authorization

    Submit initial prior authorization

    Prior authorization is required for antineoplastic medical infusion drug coverage. The request must be made by an oncologist, the therapy must be a category 1, 2A, or 2B NCCN treatment option, and the therapy must meet PHARM-056 medical-necessity criteria.

    Prior Authorization

    Support re-authorization with updated evidence

    Re-authorization requires updated clinical documentation demonstrating compliance, response, and clinical improvement or stabilization. Initial and re-authorization periods may each be approved for up to 12 months.

    Documentation Required

    Document qualifying treatment status

    Policy Background

    Antineoplastic agents may be covered when used to treat an appropriate cancer diagnosis and when the applicable prior authorization and medical-necessity requirements are met. The policy uses NCCN treatment categories as an evidence and consensus threshold; qualifying treatment options are NCCN Category 1, 2A, or 2B. Ongoing clinical benefit, including improvement or stabilization of the disease, is required for continuation therapy.

    NCCN Evidence Categories

    NCCN Category 1
    Evidence levelHigh-level evidence
    NCCN consensusUniform consensus
    AppropriatenessThe intervention is appropriate
    NCCN Category 2A
    Evidence levelLower-level evidence
    NCCN consensusUniform NCCN consensus
    AppropriatenessThe intervention is appropriate

    Initial Authorization Criteria

    Initial Authorization

    Initial coverage requires ALL of the following criteria:

    Initial authorization

    • Oncologist request

      • The request must be made by an oncologist.

    • NCCN treatment category

      • The requested therapy is listed as a category 1 option for treatment according to the NCCN Guidelines.Category 1
      • The requested therapy is listed as a category 2A option for treatment according to the NCCN Guidelines.Category 2A

    Re-authorization Criteria

    Re-authorization

    Re-authorization requires ALL of the following:

    • Updated clinical documentation

      • Updated clinical documentation must be submitted indicating compliance with and response to therapy.

    • Clinical improvement or stabilization

      • Improvement in the condition is documented.Improvement
      • Stabilization of the disease is documented.Stabilization
    Policy Summary
    PayerUniversity of Utah Health Plans
    PolicyAntineoplastics - Medical Infused Drugs
    Policy CodePolicy PHARM-M017
    Change TypeNo material change
    Effective DateJun 1, 2025
    Last ReviewMay 27, 2025
    Next Review DateMay 27, 2026
    Key ActionSubmit prior authorization requests through an oncologist and document a qualifying NCCN category 1, 2A, or 2B treatment option.
    SourceLink
    On This Page
    Coverage Criteria and ExclusionsPrior Authorization and Provider RequirementsPolicy BackgroundNCCN Evidence CategoriesInitial Authorization CriteriaRe-authorization Criteria

    Submit a prior authorization request made by an oncologist and document that the requested therapy is a category 1, 2A, or 2B NCCN treatment option and meets the medical-necessity criteria in PHARM-056.

    Documentation Required

    Document response for continuation

    For re-authorization, submit updated clinical documentation showing compliance and response to therapy, including improvement or stabilization of the disease. Demonstrated clinical improvement in the condition is required for continuation.

    Denial Risk

    Avoid excluded or contraindicated use

    Coverage may be denied when the member has a contraindication to the requested therapy, the requested use is experimental or investigational, or there is noncompliance with prior medical or pharmacological therapy.

    Denial Risk

    Meet all authorization criteria

    A request may be denied if it is not submitted by an oncologist, the requested therapy is not a category 1, 2A, or 2B NCCN treatment option, or the therapy does not meet the medical-necessity criteria in PHARM-056.

    Denial Risk

    Provide sufficient response documentation

    Continuation may be denied if updated clinical documentation does not demonstrate compliance, response, improvement, or stabilization of the disease. Demonstrated clinical improvement in the condition is required for continuation.

    Denial Risk

    Follow approved dosing

    Dosing must be performed in accordance with the therapy's approved package insert or NCCN guidelines. Dosing that does not follow these requirements may not satisfy policy requirements.

    NCCN Category 2B
    Evidence levelLower-level evidence
    NCCN consensusNCCN consensus
    AppropriatenessThe intervention is appropriate
    NCCN Category 3
    Evidence levelAny level of evidence
    NCCN consensusMajor NCCN disagreement
    Policy statusDoes not qualify under the policy
  1. The requested therapy is listed as a category 2B option for treatment according to the NCCN Guidelines.Category 2B

  2. Medical necessity

    • The requested therapy meets the medical-necessity criteria in PHARM-056, Prior Authorization and Medical Necessity.