oncology medications — Medical Mutual

Initial criteria

• Prescribed by or in consultation with a hematologist, oncologist, or a specialist with experience in treating the cancer
• If the indication specifies the prior use of another treatment or medication, the patient has had a prior trial on the agent specified
• Diagnostic or confirmatory testing has been conducted to support the use, including any specifically mentioned diagnostics or testing as noted in the FDA-approved labeling or NCCN Compendium
• The requested drug will only be used for the recommended duration for the indication or condition
• The requested dose follows the dosing guidelines outlined in the product’s most recent FDA-approved labeling
• The patient does not have any contraindications to the requested medication
• If the use specifies combination therapy, the patient will use the recommended regimen
• If the request is for a brand product with an AA- or AB-rated generic product available, either: the patient has tried the generic product OR the patient cannot take the generic product due to a clinically significant formulation difference resulting in allergy or adverse reaction per prescriber

Reauthorization criteria

• Patient has been started on the requested oncology medication
• Prescriber provides evidence of beneficial response warranting continuation of therapy
• Patients continuing use of a brand product with an AA- or AB-rated generic product available must meet brand/generic requirements as in initial criteria

Approval duration

initial 6 months; reauth 1 year