| Coverage Policy Manual | |
| Policy #: | 2000030 |
| Category: | Pharmacy |
| Initiated: | July 1999 |
| Last Review: | December 2023 |
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| Chemotherapy for Malignancy | |
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| Description: |
Chemotherapy is the treatment of a disease process with pharmaceutical drugs. Malignancies may be treated with different classes of chemotherapeutic agents including antineoplastics, hormones, and immunomodulating agents.
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Policy/ Coverage: |
Effective November 1, 2021
Cancer chemotherapeutic agents meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes and are covered for their FDA approved labeling.
Coverage for the off-label use of cancer chemotherapeutic agents is allowed if:
Articles from the following journals are considered:
Please refer to a separate policy on Site of Care or Site of Service Review (policy #2018030) for pharmacologic/biologic medications.
Chemotherapy for indications not listed as labeled, or is not consistent with off-label determinations as described above, does not meet member benefit certificate primary coverage criteria that there be scientifc evidence of effectiveness in improving health outcomes.
For contracts without primary coverage criteria, the use of chemotherapy for indications not listed as labeled, or is not consistent with off-label determinations as described above, is considered investigational.
Investigational services are specific contract exclusions in most member benefit certificates of coverage.
Effective June 2019 to October 31, 2021
Cancer chemotherapeutic agents meet primary coverage criteria for effectiveness and are covered for their FDA approved labeling.
Coverage for the off-label use of cancer chemotherapeutic agents is allowed if:
Articles from the following journals are considered:
Please refer to a separate policy on Site of Care or Site of Service Review (policy #2018030) for pharmacologic/biologic medications.
Chemotherapy for indications not listed as labeled, or is not consistent with off-label determinations as described above, does not meet Primary Coverage Criteria for effectiveness.
For contracts without Primary Coverage Criteria the use of chemotherapy for indications not listed as labeled, or is not consistent with off-label determinations as described above, is considered investigational. Investigational services are an exclusion in the member certificate of coverage.
Effective 3/15/2011 - May 2019
Cancer chemotherapeutic agents meet primary coverage criteria for effectiveness and are covered for their FDA approved labeling.
Coverage for the off-label use of cancer chemotherapeutic agents is allowed if:
Articles from the following journals are considered:
Chemotherapy for indications not listed as labeled, or is not consistent with off-label determinations as described above, does not meet Primary Coverage Criteria for effectiveness.
For contracts without Primary Coverage Criteria the use of chemotherapy for indications not listed as labeled, or is not consistent with off-label determinations as described above, is considered investigational. Investigational services are an exclusion in the member certificate of coverage.
Effective prior to 3/15/2011
Cancer chemotherapeutic agents meet primary coverage criteria for effectiveness and are covered for their FDA approved labeling.
Coverage for the off-label use of cancer chemotherapeutic agents is allowed if:
An off-label use identified by a compendium as medically accepted if the indication is Category 1 or 2A in the NCCN compendium.
Articles from the following journals are considered:
Chemotherapy for indications not listed as labeled, or is not consistent with off-label determinations as described above, does not meet Primary Coverage Criteria for effectiveness.
For contracts without Primary Coverage Criteria the use of chemotherapy for indications not listed as labeled, or is not consistent with off-label determinations as described above, is considered investigational. Investigational services are an exclusion in the member certificate of coverage.
Coverage statement effective Jul 20, 2010- March 14, 2011
Cancer chemotherapeutic agents meet primary coverage criteria for effectiveness and are covered for their FDA approved labeling.
Coverage for the off-label use of cancer chemotherapeutic agents is allowed if:
Articles from the following journals are considered:
Chemotherapy for indications not listed as labeled, or is not consistent with off-label determinations as described above, does not meet Primary Coverage Criteria for effectiveness.
For contracts without Primary Coverage Criteria the use of chemotherapy for indications not listed as labeled, or is not consistent with off-label determinations as described above, is considered investigational. Investigational services are exclusions in the member certificate of coverage.
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| Rationale: |
This policy is mandated by Act 270, originally passed in 1999 and revised by the Arkansas legislature in 2009.
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| References: |
Arkansas State Law; Act 466; 1999. Clarification of Standards for Coverage of Cancer Medications. Act 270, Section 1, A.C.A. 23-79-147(b)(1). |
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Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
CPT Codes Copyright © 2024 American Medical Association. |
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