ATT018_XP001_PharmacyCAFA.pdf

Pharm-XP-001

Cancer Formulary Assignment (CAFA) External Standard Operating Procedure

Original Publication June 2022 Revised March 2025

Introduction This guide describes the processes for the Cancer Formulary eligibility assignment for new and current members.

Background On October 12, 2012, the World Trade Center (WTC) Health Program expanded its coverage, adding many types of cancer as a covered condition. This change created the need for specialized care that exceeded the capabilities of the Clinical Centers of Excellence (CCEs), hindering their ability to effectively manage and coordinate treatment.

To address this need, the Program introduced a Cancer Formulary with fewer point-of-sale restrictions. Key differences between the Cancer Formulary and the Standard Formulary include:

• An open prescriber network (no provider blocks)

• A wider selection of drugs with reduced prior authorization (PA) requirements

• Increased quantity limits for controlled substances

Most medications on the Cancer Formulary are also available on the Standard Formulary.

However, since many members certified for cancer are not currently undergoing treatment, the Program reserves access to the Cancer Formulary exclusively for those who have received active treatment within the past year.

To facilitate this process, a Cancer Formulary Assignment (CAFA) form was created based on specific criteria. All certified members are initially assigned to the Standard Formulary.

If a member meets the eligibility criteria outlined below, they must be opted into the Cancer Formulary using the CAFA form. Conversely, if they no longer meet these criteria, they should be reverted to the Standard Formulary using the same CAFA form.

Approving Authority The Clinical Director of the CCE/NPN (Nationwide Provider Network) has the authority to approve CAFA forms. They may also designate qualified staff members to act as authorizers.

The CCE/NPN is responsible for training these authorizers and monitoring their actions to ensure compliance with established policies and procedures. Ultimately, the CCE/NPN Clinical Director is accountable for all CAFA forms submitted by the designated authorizers.

Cancer Formulary Eligibility Criteria

1. Be certified for a cancer diagnosis (exceptions: non-melanomatous skin cancer; or papillary, follicular, or medullary thyroid cancer that is not persistent or recurrent), AND

2. Meet the criteria for and be currently receiving Intensive Case Management (ICM) services, AND

3. Satisfy at least one (1) of the following criteria:

a. Receiving active or recent treatment for cancer within the past 12 months

(e.g., chemotherapy, tumor resection, cancer-related surgery, radiation therapy, immunotherapy, targeted therapy, hormone therapy)

b. Receiving active or recent treatment for cancer complications, medically associated conditions (MAC), or paraneoplastic conditions within the past 12 months (e.g., hypercoagulable disorders, Cushing syndrome, hypercalcemia)

c. Ever received a Program-covered bone marrow/stem cell transplant.

d. Be in an immunocompromised status, such as but not limited to:

i. Recurrent or persistent infectious processes

ii. Poor response to treatment for infections

iii. Delayed or incomplete recovery from illness

iv. Frequent yeast infections

v. Hemato-proliferative disorders

vi. Hematological malignancy

vii. Abnormal labs, such as but not limited to:

1. Complement levels

2. Immunoglobulin levels

3. Protein electrophoresis

4. T lymphocyte count

5. Leukopenia

6. Neutropenia

Process and Procedure CAFA Process

1. All certified members are automatically assigned to the Standard Formulary.1

2. Members with cancer certifications should be periodically evaluated for eligibility for the Cancer Formulary, including at the time of certification, when a relapse/recurrence occurs, or periodically by a case manager. At any time, if it is determined the member meets the criteria, the CCE/ NPN should complete and submit the CAFA form electronically through electronic prior authorization (ePA) (preferred method) or using the paper form by fax, along with any supporting documentation. All CAFA forms are submitted from the CCE/NPN to the Express Scripts (ES) Coverage Review Department (CRD) and then routed to the WTC Health Program Pharmacy Benefits Team (PBT) for review.

2.1. Fax: Fax the paper CAFA form with supporting documentation to 877-251- 5896. The most up to date CAFA form can be found on the ES Online Document Repository.

1 Exception is FDNY family mental health

2.2. ePA: The preferred method for submitting CAFA change requests is through the CCE/NPN ePA platform (e.g., CoverMyMeds, Surescripts, electronic health record (eHR), etc.). Process for submitting CAFA change requests via ePA:

2.2.1. Select the drug “CAFFEINE 200 mg TABLETS” to submit a CAFA change request. Selecting any other drug will not allow you to complete the CAFA change request via ePA.

2.2.2. After selecting “CAFFEINE 200 mg TABLETS”, the CAFA change request form will be displayed electronically for the provider to complete. Any additional documentation can be submitted with the ePA.

3. Once submitted to ES CRD, a case will be created in OnePA within 24 hours of receipt, which will then be routed to the PBT for review along with any documentation that was submitted by the CCE/NPN.2

3.1. The case will be visible in the Customer Service Portal (CSP) once it has been built in OnePA, under the Coverage Review Status screen which will show what step the PA is in during a review.

3.2. If no PA status is available, please contact ES CRD via phone at 844-431-9672 or via CARE to check on status.

4. PBT staff will access OnePA, review the CAFA request(s), then note the approval or denial decision in OnePA.

5. PBT staff will submit approval or denial decisions to Karna daily via the WTC Health Program CARE portal.

6. Karna will send an eligibility feed to ES that will be uploaded the next business day where the new formulary will be updated on the member’s profile and activated in the system.

7. CAFA change requests will be processed within three business days. The CCE/NPN must check CSP to confirm formulary placement.

8. In cases where a drug is excluded from the Standard Formulary (i.e., rejects “drug not covered”) but is on the Cancer Formulary, the CAFA form will have to be processed and approved before the prescription can be processed. If a prescription is pending for a drug that is on the Standard Formulary, the prescription can be processed, or the PA can be submitted prior to processing the CAFA form.

9. The CCE/NPN should periodically re-evaluate members on the Cancer Formulary to ensure they still meet criteria.

10. If it is determined that a member no longer meets the Cancer Formulary eligibility criteria, the CCE/NPN should use the same steps above to transition them back to the Standard Formulary.

2 The CCE/NPN will not have access to OnePA

Quality Controls The Program requires Clinical Centers of Excellence (CCEs) and the Nationwide Provider Network (NPN) to conduct Quality Assurance (QA) checks twice a year to ensure that members are appropriately assigned to the Cancer Formulary. These semi-annual audits require CCE and NPN staff to evaluate at least 25% of members assigned to the formulary to confirm their appropriate assignment.

Additionally, clinics must perform monthly retrospective reviews of prescription claims for cancer medications. This review should cover 5% of approved pharmacy claims for members with certified cancer conditions who are on the Cancer Formulary. Clinics are expected to identify any members who no longer meet the eligibility criteria for the Cancer Formulary, and take corrective actions as needed to ensure that eligible members are added.

Acronyms and Definitions

Term Definition CAFA Cancer Formulary Assignment

CCE Clinical Center of Excellence

CRD Coverage Review Department

CSP Customer Service Portal eHR Electronic Health Record ePA Electronic Prior Authorization

ICM Intensive Care Management

MAC Medically Associated Conditions

NPN Nationwide Provider Network

OnePA Express Scripts Prior Authorization system

PBT Pharmacy Benefits Team

Revision History March 2025 Updated formatting to new template, minor editorial changes to Background, Approving Authority, and Quality Controls sections to enhance readability and better align with Plain Language requirements.

November 2024 Updated language to reflect changes to TGD 3, reorg team name changes, and Express

Scripts branding change.

August 2023 Process and Procedure section to address the new systems changes from PBM/ESI, and various minor technical changes that don’t affect content.

February 2023 Added section on Approving Authority.

June 2022 Initial publication.