cancer chemotherapy medications covered under the pharmacy benefit and subject to step therapy and/or prior authorization — Highmark

Initial criteria

• ALL of the following (A, B, and C):
• A. The requested product is an FDA-approved federal legend product.
• B. The drug being requested is classified as a cancer chemotherapy medication.
• C. ONE of the following (1 or 2):
• 1. Treatment of the member’s diagnosis with the requested agent is supported by an NCCN grade 1, 2A, or 2B Category of Evidence and Consensus recommendation per the NCCN Compendia.
• 2. The prescriber submits appropriate documentation (e.g., peer-reviewed published literature) supporting the use of the requested product for the member’s diagnosis.

Approval duration

up to a lifetime authorization