Chemotherapy

The terms of compensation for chemotherapy medications are stated in the participating physician group's (PPG's) Provider Participation Agreement (PPA).

Chemotherapy and chemo adjunct medications are composed of antineoplastic and adjunctive medications. An antineoplastic medication is a compound used to destroy malignant cancer cells or shrink or kill malignant tumor cells circulating in the blood and lymphatic systems. Antineoplastics must be approved by the Food and Drug Administration (FDA) for a specific cancer indication or listed in the most recent bulletin by the Association of Community Cancer Centers to be eligible for coverage under a Health Net benefit plan.

Adjunctive medications are additional pharmaceutical agents added for the purposes of palliative symptomatic treatment of side effects directly related to the chemotherapy treatment regimen. The specific purpose of the adjunctive therapy is for a defined duration of therapy, for only as long as the chemotherapy is continued, and may not be used for chronic maintenance use. Adjunctive therapy may not include products that are already part of the outpatient pharmacy benefit program.

Refer to the Health Net Injectable HCPCS/DOFR Crosswalk (PDF) table for chemotherapy and chemo adjunct medications.

Chemotherapy medications may be administered by a participating provider in a hospital inpatient setting, at the PPG, at other patient settings, or in the member's home. Some chemotherapy agents may require prior authorization. Refer to the Health Net Injectable Prior Authorization Guidelines on the Health Net provider portal (Commercial, Medi-Cal).