CurrentMass General Brigham Health PlanPolicy N/A

Oncology medication coverage aligned to NCCN guidelines

Defines prior authorization and coverage criteria for oncology medications based on NCCN Categories of Evidence and Consensus for Mass General Brigham Health Plan members; applies to drugs under the plan's medical and pharmacy benefits.

Policy Summary

PayerMass General Brigham Health Plan

PolicyOncology medication coverage aligned to NCCN guidelines

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionObtain prior authorization and document NCCN guideline indication or current receipt of therapy for coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsapproval duration

1, 2A, 2Baccepted NCCN categories

All Plansplan applicability

Prior Authprogram type

Coverage Criteria

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Continuity for current treatment: Member is new to Mass General Brigham Health Plan and is currently receiving the requested medication (authorization excludes drugs obtained as samples or via manufacturer patient assistance programs)

Approvals granted for 12 months

NCCN guideline indication: The drug is being used as indicated by National Comprehensive Cancer Network (NCCN) guidelines with Category of Evidence and Consensus of 1, 2A, or 2B

Approvals granted for 12 months

Requests for authorization will be excluded when the product was obtained as samples or provided through a manufacturer's patient assistance program. Authorization for members new to Mass General Brigham Health Plan is permitted only when the member is currently receiving the requested medication and the product was not acquired as a sample or via a manufacturer patient assistance program.

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Members new to the Mass General Brigham Health Plan who are currently receiving treatment with the requested medication may be granted authorization; however, authorization is not available when the product was obtained as samples or via manufacturer patient assistance programs.

Contact for Specialty Medications: Phone 877-519-1908; Fax 855-540-3693
Contact for Non-Specialty Medications: Phone 800-711-4555; Fax 844-403-1029

Step Therapy

Step Therapy Program

Step therapy is in effect for this medication class. Specific step sequences are not provided in this policy; follow the plan's step therapy program requirements when applicable.

Documentation Required

Documentation must demonstrate that the drug is being used consistent with NCCN guidelines and that the member's current therapy meets the coverage criteria. Provide documentation showing the NCCN indication and the member's current therapy regimen.

NCCN indication with Category of Evidence and Consensus (1, 2A, or 2B) when applicable
Clinical notes or records documenting current therapy and treatment history

Denial Risk

Denial Risk — Prior Supply Source

There is a potential denial risk for members new to the plan when the product was obtained as samples or through manufacturer patient assistance programs; such scenarios may make the member ineligible for authorization.

Verify source of prior medication supply; samples or patient assistance program supplies may affect eligibility for authorization

Background

The policy aligns oncology medication coverage decisions with recommendations from the National Comprehensive Cancer Network (NCCN). Providers must document that the requested drug is being used in accordance with NCCN guidance and applicable Categories of Evidence and Consensus (Categories 1, 2A, or 2B) when seeking authorization. Approvals issued under these criteria are time-limited and, when granted, are typically for 12 months.

NCCN Evidence Category Definitions

NCCN Category 1

DefinitionRecommendation based on high-level evidence (e.g., high-powered randomized clinical trials or meta-analyses) with uniform consensus that the recommendation is indicated (uniform = near unanimous positive support with some possible neutral positions).

Evidence examplesHigh-powered randomized clinical trials or meta-analyses.

Consensus meaningUniform consensus denotes near-unanimous positive support among panel members, though some neutral positions may exist.

NCCN Category 2A

DefinitionRecommendation based on lower-level evidence but with uniform consensus that the recommendation is appropriate; lower-level evidence can include phase II trials, large cohort studies, case series, or expert/practice experience.

Evidence examplesPhase II studies, large cohort studies, case series, or individual practitioner experience.

ImplicationThese recommendations may be superseded as higher-level evidence becomes available.

NCCN Category 2B

DefinitionRecommendation based on lower-level evidence with nonuniform consensus among panel members; multiple reasonable approaches may exist because the evidence is not conclusive.

Practical noteNonuniform consensus indicates institutions may adopt different management approaches rather than a major disagreement.

Signal to usersA Category 2B designation signals that more than one approach can be inferred from existing data.

NCCN Category 3

DefinitionRecommendation that has engendered major disagreement among panel members; used when substantial interpretation issues exist regarding the data or generalizability of trial results.

Causes of disagreementDirect comparison absence between interventions, differing interpretations of available data, or disagreement about generalizability of trial findings.

User actionCategory 3 alerts users to interpretation controversy and directs them to the cited manuscripts for explanation of the controversy.