Medicare Coverage of Cancer Therapeutics


Overview

 

CMS and its intermediaries and carriers cover specific indications for the use of drugs and biologics if such indications are listed in recognized compendia. In 2005, three compendia were recognized for Medicare coverage of cancer therapeutics. One was ceasing publication. The two other compendia were not frequently updated, and new cancer scientific data were not reflected in a timely manner. Therefore, Medicare beneficiaries were frequently denied coverage for medically-accepted uses of cancer drugs and biological products. 

 

3-P Strategy

 

  • Policy: Oncologists relied on the National Comprehensive Cancer Network Drug and Biologic Compendium™ (the NCCN compendium) as the authoritative source in decisions about the indication of drugs and biologics beyond the FDA-approved labeling for cutting-edge cancer care. Legislation was required to add the NCCN compendium to the list of approved compendia for Medicare coverage of cancer therapeutics.

  • Positioning: Established a coalition of oncologists, cancer centers, scientific organizations and patient advocacy organizations to encourage Congress to add the NCCN compendium to the list of approved publications for Medicare cancer care coverage determinations.

  • Pursuit: Conducted more than 75 meetings with Members of Congress and Congressional committees to secure passage of legislation to add the NCCN compendium as an approved source regarding coverage determinations about the use of drugs and biologics in cancer care.

 

Outcome

Secured a provision in the Medicare Improvement and Patient Assistance Act (MIPAA) to add the NCCN Drugs and Biologics Compendium™ as a mandated reference for Medicare overage determinations, ensuring these life-saving therapies would be covered by Medicare. 

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