NCCN Concordance Doesn't Guarantee Cancer Drug Coverage

Guideline concordance with the National Comprehensive Cancer Network (NCCN) has become the common language shared by oncology payers and providers, but agreeing on the guidelines is often just the starting point of the coverage conversation, not the end of it, according to experts.

Ryan Haumschild, PharmD, vice president of pharmacy for Emory Healthcare and the Winship Cancer Institute, moderated the panel discussion at The American Journal of Managed Care^®’s annual Patient-Centered Oncology Care® conference, held in Nashville, Tennessee, September 24-25, 2026.

How Far Does NCCN Concordance Actually Extend?

Payer coverage of NCCN-listed regimens has narrowed sharply in recent years, said Terra Wonsettler, PharmD, MBA, vice president of oncology pharmacy policy and clinical evidence at Evolent. Health plans once covered treatment options up through category 3, but category 2B recommendations are now frequently excluded; even category 2A status is being reconsidered by some payers.

“Times are changing exceptionally fast,” Wonsettler said.

Categories 1 and 2A require high-validity clinical trial data and agreement from more than 85% of an NCCN expert panel; category 2B reflects a closer 51% majority with less supporting trial data; and category 3 recommendations draw so little consensus that they rarely generate disputes between payers and providers, explained Rogelio “Roger” Brito, DO, a practicing oncologist who also advises for EmblemHealth.

Haumschild compared the resulting menu of guideline-listed options with the Cheesecake Factory’s menu: something for nearly every clinical scenario, which can make it harder to pin down what “NCCN coverage” means from plan to plan.

“How do we start to make it more specific?” he asked.

Why Guideline Concordance Doesn't Guarantee Approval

For Kiana Mehring, MBA, who oversees payer strategy and value-based care at Florida Cancer Specialists & Research Institute (FCS), NCCN concordance functions as a shared baseline rather than a coverage guarantee. FCS measures its own regimens as 100% NCCN concordant, Mehring said, but a recent study conducted with Avalere found that the leading reasons for prior authorization denials were noncoverage and step-edit requirements, not concerns about clinical appropriateness.¹

"Even when care is NCCN concordant, that doesn't necessarily mean [payer] approval," she said. "Cost often gets the final say."

Complicating matters further, Tracy Spinks, director of value-based care at Optum, noted that the payer making coverage decisions is often the employer itself, adding even more variability.

“UnitedHealthcare has more than 30,000 separate formularies [or] benefit designs for those employers,” she explained. “That just makes it exponentially harder to answer this question easily, to say, ‘Well, one may consider cost; another one might not.’”

Can Payer Review Cycles Keep Pace With Guideline Updates?

NCCN pushed out 481 guideline updates over an 8-month period, Spinks said, a volume that strains health plan infrastructure built around quarterly, rather than continuous, review cycles. Brito said the pharmacy and therapeutics (P&T) review process he advises payers on typically takes at least 4 weeks, compared with the 2-week cycle some provider organizations described earlier in the meeting.

"Already, we're behind the 8-ball on our policies," he said.

FCS has tried to close that gap by holding P&T reviews every other week, flagging anticipated guideline changes to payers before they take effect, and offering oncology expertise that many health plans lack in-house, Mehring said. Spinks pointed to artificial intelligence and broader adoption of Fast Healthcare Interoperability Resources standards as tools that could shorten the operational lag between a guideline update and a corresponding policy change, even if the underlying review timeline stays the same.

Haumschild added that AHIP has been committed to reducing prior authorization burden,² which he said could translate into greater use of automated approvals drawing on pharmacy claims or prescription data.

Rethinking Value Beyond a Drug's Sticker Price

Panelists also pushed back on evaluating oncology regimens by acquisition cost alone. Brito argued that the most expensive drug is sometimes the right treatment.

“If you are giving the best treatment, you should have better outcomes [for] those patients,” he said, adding that those patients who are responding may need less frequent restaging, fewer hospitalizations, and fewer emergency department visits, an argument that has found mixed reception among self-funded employers.

Real-world evidence (RWE) is increasingly filling gaps left by clinical trials, Spinks said, though building a dataset large enough to detect meaningful differences can still take 1 to 2 years. Brito cautioned that RWE cuts both ways: some category 1 recommendations approved on trial data have failed to hold up 6 to 18 months later in broader practice.

Misaligned incentives, including manufacturer rebates that can favor a given drug for either a payer or a provider, remain a barrier to value-based contracting, Mehring and Brito said. Spinks added that 2-sided risk arrangements are especially difficult in oncology because patient-level variation can distort results in the small populations typical of value-based pathway models.

What Would Improve Guideline-Concordant Access?

Asked what single change would most improve NCCN-concordant access, panelists pointed to electronic health record modernization and shared data infrastructure (Wonsettler); NCCN guidance that incorporates total cost of care factors such as biomarker testing, imaging, and radiation oncology, alongside continued investment in lower-cost sites of service (Brito); a more holistic view of the full oncology care journey rather than siloed medical or pharmacy benefit reviews (Mehring); and greater transparency so patients and employers understand their financial obligations before treatment begins (Spinks).

Haumschild closed the panel by framing guideline concordance as necessary but incomplete on its own.

"Guideline-concordant care is so important, but it has to be done in the context of total cost of care and cost-effective therapies for sustainability of care and treatment," he said.

References

1. Florida Cancer Specialists & Research Institute issues call for action to protect timely access to cancer care. News release. Florida Cancer Specialists & Research Institute. May 6, 2026. Accessed September 25, 2026. https://www.flcancer.com/articles/shining-a-light-payer-management/

2. Health plans reduce prior authorization, support continuity of care and enhanced consumer communications. News release. AHIP. April 7, 2026. Accessed September 25, 2026. https://www.ahip.org/news/articles/health-plans-reduce-prior-authorization-support-continuity-of-care-and-enhanced-consumer-communications