TABLE 1.

Operational Definitions

Term	Definition
Traditional management tools
Quantity limits	Payer defines how much of a drug the patient can get during a specified time period
Manage to label	Payer restricts use to FDA-labeled indication
Split fills	Program where pharmacy can provide a partial fill of the member’s first prescription before filling the full specified time period of a prescription
Reauthorizations	Reauthorization to continue therapy must be sought at regular intervals
Step edits for products recommended in the same line of therapy by NCCN compendia	Payer requires patient to try a preferred drug before trying the product if the step edit follows NCCN compendia
Step edits independent of NCCN guidelines	Payer requires patient to try a preferred drug before trying the product where this step edit does not follow NCCN compendia
Blocking agents and having them only available by medical exception	Payer does not allow access to a product except through a medical exception or an appeal process by the physician; such an approach requires a significant administrative effort from the prescriber
Preferred through tiering	Payer uses copay differentials to influence preference toward specific drugs
Oncology-specific management tools
Pathways without risk	Comprehensive, evidence-based treatment protocols that give direction on how to provide cancer care; pathways without risk incentivize physicians to follow the pathway with an upside risk (e.g., positive financial incentive)
Pathways with risk	Comprehensive, evidence-based treatment protocols that give direction on how to provide cancer care; pathways with risk incentivize physicians with downside and upside risk (e.g., a fee is implemented if pathway is not followed, or overall clinician reimbursement rate is dependent on the adoption of the implementation of the pathway)
Buy-and-bill incentives to influence preference toward branded agents	Payer provides a higher reimbursement rate to clinicians for preferred branded products
Buy-and-bill incentives to influence preference towards generics	Payer provides a higher reimbursement rate to clinicians for generic products
Systemic management tools
Pursuing oncology-specific models, such as oncology care models	A payment delivery model where participating groups provide enhanced patient services, use data to drive continuous quality improvement, and use certified electronic health record technology. Participants in the CMS OCM program receive a monthly enhanced oncology services payment of $160 per beneficiary, performance-based payment for OCM episodes, and regular fee-for-service payments
Shifting financial risk through payment system (e.g., bundled payments)	A cost-saving measure where reimbursement is based on expected costs of episodes of care
Restructuring provider networks based on their ability to manage oncology cost	Payers reduce the network of providers and only contract with oncology centers showing the most rational and cost-minimizing use of resources

CMS = Center for Medicare & Medicaid Innovation; FDA = U.S. Food and Drug Administration; NCCN = National Comprehensive Cancer Network; OCM = Oncology Care Model.