CurrentMass General Brigham Health PlanPolicy N/A

Oncology Medication Prior Authorization Using NCCN Guidelines

Defines prior authorization criteria for oncology medications under the pharmacy benefit for Mass General Brigham Health Plan commercial/exchange members, using NCCN guideline categories to determine coverage for requested agents.

Policy Summary

PayerMass General Brigham Health Plan

PolicyOncology Medication Prior Authorization Using NCCN Guidelines

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionObtain prior authorization under the pharmacy benefit and document NCCN Category 1, 2A, or 2B evidence or that the member is currently receiving the medication if new to the plan.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Commercial/ExchangePlan applicability

Prior AuthorizationProgram type

1,2A,2BNCCN evidence categories accepted

12 moApproval duration

Coverage Criteria

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Authorization criteria

Authorization may be granted when ONE of the following is met:

continuation_for_new_member: Member is new to the plan and is currently receiving the requested medication (excludes products obtained as samples or via manufacturer patient assistance programs).

Supports continuity of care.

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

NCCN categories must be documented.

Products obtained as samples or through a manufacturer's patient assistance program are excluded from authorization for members who are new to the plan. Authorization for a new member may only be considered when the member is currently receiving the requested medication and the product was not obtained as a sample or via manufacturer assistance.

Provider Actions and Requirements

Prior Authorization

Prior authorization required for pharmacy benefit (Commercial/Exchange)

Prior authorization is required under the pharmacy benefit for Commercial/Exchange members; approval is granted when the drug is being used as indicated by NCCN guidelines with Category 1, 2A, or 2B, or for members new to the plan who are currently receiving the requested medication (excluding products obtained as samples or via manufacturer's patient assistance programs).

Applies to the pharmacy benefit for Commercial/Exchange members.
Authorization supports continuity of care for members new to the plan who are currently receiving the medication, except for samples or manufacturer assistance products.

Step Therapy

Step therapy not required

No step therapy requirement is specified in this policy.

Documentation Required

Required documentation: NCCN category and current treatment status

Provide documentation that the drug is being used as indicated by NCCN guidelines with a Category of Evidence and Consensus of 1, 2A, or 2B; if the member is new to the plan, document that the member is currently receiving the requested medication (note: products obtained as samples or via manufacturer's patient assistance programs are excluded).

Document NCCN category (1, 2A, or 2B) supporting the indication.
For new-to-plan members, document current receipt of the requested medication (excluding samples or manufacturer assistance).

Denial Risk

Denial triggers: noncompliance with NCCN categories or use of samples/assistance products

Requests may be denied if the member is not currently receiving the requested medication and the use does not meet NCCN guideline Categories 1, 2A, or 2B, or if the product was obtained as samples or via manufacturer's patient assistance programs.

Denial can occur for lack of documentation of NCCN Category 1/2A/2B indication.
Denial can occur for products obtained as samples or through manufacturer assistance programs.

Definitions

NCCN Categories of Evidence and Consensus — Definitions

Category 1Recommendation based on high‑level evidence (e.g., high‑powered randomized clinical trials or meta‑analyses) with uniform panel consensus that the recommendation is indicated.

Category 2ARecommendation based on lower‑level evidence (phase II, cohort studies, case series, or expert experience) but with uniform consensus that the recommendation is appropriate.

Category 2BRecommendation based on lower‑level evidence with nonuniform consensus among panel members; indicates multiple acceptable approaches due to inconclusive evidence.