Temozolomide (Temodar®)

By September 15, 2026: Billing team must prepare for implementation of this new Temozolomide coverage policy. REQUIREMENTS: (1) Update billing system to require prior authorization for all Temozolomide claims with diagnosis codes matching covered indications (glioblastoma, anaplastic astrocytoma, CNS metastases, Ewing sarcoma, neuroendocrine tumors, pheochromocytoma/paraganglioma, melanoma, mycosis fungoides/Sézary syndrome, SCLC, soft tissue sarcoma, uterine sarcoma, neuroblastoma); (2) Configure prior auth to automatically grant 12-month authorizations when coverage criteria are met; (3) Build logic to verify line of therapy (e.g., first-line for pheochromocytoma, second-line for Ewing sarcoma); (4) For neuroblastoma claims, require documentation of combination therapy with approved agents (irinotecan, dinutuximab/naxitamab-gqgk, sargramostim); (5) Create continuation of therapy pathway allowing 12-month reauthorization if no disease progression or unacceptable toxicity documented; (6) Update encounter forms and provider education materials to reflect new policy effective date; (7) Train billing and prior auth staff on 12 covered indications and specific criteria; (8) Flag that any use outside listed indications remains experimental/investigational and non-covered. Claims submitted before 9/30/26 using this policy will be denied. After effective date, claims lacking proper prior auth will be denied. Providers must reference NCCN Guidelines, Drugdex, or AHFS for dosage and monitoring guidance.