Medicare Recognizes NCCN Compendium
Authors: William T. McGivney
Journal: Journal of the National Comprehensive Cancer Network (2008)

Medicare Recognizes NCCN CompendiumOn June 5, 2008, The Centers for Medicare and Medicaid Services (CMS) recognized the NCCN Drugs & Biologics Compendium (NCCN Compendium) as an authoritative source of information to be considered regarding coverage determinations about the use of drugs and biologics in cancer care.CMS and its intermediaries and carriers cover specific indications for the use of drugs and biologics if such indications are listed in recognized compendia.The main use of drug compendia is in decisions about indications of drugs beyond the FDA-approved label.At this writing, 2 other compendia are recognized: the American Hospital Formulary Service Compendium (AHFS) and DrugDex.The all important guidance from CMS to carriers and intermediaries on the use of the NCCN Compendium and other compendia likely will be released by the end of July 2008.The NCCN Compendium fully met the criteria established by the Medicare Evidence Development Coverage Advisory Committee (MedCAC) at its March 30, 2006 meeting.Of the 6 compendia evaluated by the MedCAC at that meeting, the NCCN Compendium received the best scores, by far, on important characteristics such as being evidence-based, having public transparency for evaluation of therapies, and including identification and notification of potential conflicts of interest.The recognition by CMS of the NCCN Compendium is the result of a collaborative effort over 3 years between the agency and the NCCN.The NCCN has added many features, such as a multi-faceted search capacity to facilitate use by decision-makers.Importantly, as noted by CMS, NCCN makes the NCCN Compendium available free of charge to all end-users, including clinicians, patients, and managed care medical directors.Medicare recognition follows the announcement on January 16 of this year by United HealthCare that they would become the first private payor to base chemotherapy drug coverage decisions on the NCCN Compendium.Further, 2 other large payors have indicated that, although they currently do not anticipate making public announcements, they are integrating the NCCN Compendium into their coverage policy grids.Many private payors will likely follow suit.The recognition, application, and direct influence of the NCCN Compendium in coverage policy is significant from a health policy perspective.After almost 15 years of coverage policy and decisions becoming more 1-sided from a payor perspective, the growing recognition and use of the NCCN Compendium provides clinicians with direct and substantial influence over coverage policies that impact the availability of and access to innovative therapies.Given that payors often base coverage policies on the NCCN Clinical Practice Guidelines in Oncology, clinicians, through input into or participation on NCCN guidelines panels, have importantly and appropriately reestablished influence over what constitutes appropriate care in areas beyond the scope of pharmacotherapy.Finally, it is clear that, increasingly, NCCN guidelines recommendations are becoming the basis for evaluation of the quality of oncologic care by private payors.Specific issues also deserve mention.When Medicare has a national coverage determination, this determination takes precedence in setting coverage policy over all recognized compendia.In the Medicare program, all categories of NCCN recommendations appear to be covered.For United HealthCare, recommendation categories 1, 2A, and 2B will be automatically covered.Category 3 recommendations will be referred for manual review.Under the Medicare program, the use of the NCCN Compendium is currently recognized for only Part B. Legislation is pending that would extend the recognition of all compendia recognized under Part B to Part D. This is important given the increasing availability of oral agents.In 2008 and 2009, the NCCN will gradually introduce standard chemotherapy order templates.These templates will be built directly from the NCCN guidelines and compendium.Thus, the templates will reflect, in almost all cases, regimens and indications covered by managed care companies and the Medicare program.These templates have the potential to help practices and centers stay up to date, enhance safety in prescription and administration, and reduce the back and forth between practice and payors.An introductory preview of the first 20 standard chemotherapy order templates is online at www.nccn.com.The recognition of the NCCN Compendium represents an important milestone in establishing an authoritative voice that comes directly from the practicing oncology community to the processes that establish coverage policies.CMS recognition of the NCCN Compendium was the result of efforts of the NCCN and other major organizations in oncology.The NCCN will continue to work with you, our colleagues in the oncology community, to inform and improve decision-making processes on behalf of the patients whom we serve.