Oncology Drugs

    Drug - Oncology drugs

    July 2025

    Therapeutic Area - Oncology

    Approval criteria

    A request for coverage of an oncology drug may be approved if the following criteria are met

    • The drug is not excluded from coverage (e.g., drug that is not part of the federal Medicaid Drug Rebate Program) AND
    • The prescriber is a specialist in the area of the patient’s diagnosis (e.g., oncologist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis; AND
    • The patient does NOT have any FDA labeled contraindications to the requested drug; AND
    • The drug is prescribed for ONE of the following:
      • A medically accepted indication as defined in Section 1927 of the Social Security Act; OR
      • An indication that is consistent with NCCN (National Comprehensive Cancer Network) recommendation with a level of evidence of Category 1 or 2A.
      • Continuation of therapy (patient has had at least one treatment or one fill immediately preceding the prior authorization request).  The use of free goods or pharmaceutical samples will not be considered as meeting this criterion

    Duration of Approval

    • Initial approval will be provided for six months or for the maximum treatment duration described in the FDA-approved label or NCCN guidelines, whichever is less.
    • Renewal approval will be provided annually thereafter if the following are met:
      • There is no progression of disease or progression has been slower than otherwise would have been expected in this patient population; AND
      • Absence of treatment-restricting adverse effects attributable to the requested drug; AND
      • Approval will not be authorized beyond maximum treatment duration or number of treatments described in the FDA-approved label or NCCN guidelines.

    Quantity limits

    The requested drug is being prescribed within recommended dosing guidelines

    Billing for oncology drugs

    If administered by a healthcare professional, the requested drug must be billed as a medical claim

    Definition

    Free goods or pharmaceutical samples: medication samples, medications obtained from any patient assistance programs or any discount programs, medications obtained through free trial programs, manufacturer vouchers, coupons, or debit cards while the member is on Medical Assistance.

    Covered drugs

    The list of oncology drugs covered by this policy can be found on the MHCP Oncology Drug List (PDF) posted in Forms and Documents on the Minnesota Medical Assistance Portal hosted by Prime Therapeutics.

    Questions

    Provider Call Center: (844) 575-7887

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