# Tie coverage and copays to the ESMO benefit scale

Source: https://onco.cc/ideas/idea-cost-value-scale-in-coverage/  
OnCo record `idea-cost-value-scale-in-coverage` (Idea). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Oncology has two respected scales that grade how much a drug helps in each indication; payers could set low copays for high-grade uses and require a conversation for low-grade ones instead of blanket prior authorisation.

## Summary

The ESMO Magnitude of Clinical Benefit Scale grades each indication from 1 to 5 (palliative) or A to C (curative); the ASCO Value Framework produces a net health benefit score; ICER publishes cost-effectiveness reviews. Value-based insurance design lowers cost sharing for high-value care. Applying the scales to oncology formularies (zero copay for ESMO-MCBS 4 and 5 indications, standard review for 1 and 2) would target scrutiny where benefit is smallest and remove it where the case is clear, without any payer inventing its own scoring.

## Fields

- Kind: Idea
- Last checked: 2026-09-10
- Hypothesis: Value-tiered oncology formularies will cut prior authorisation volume for high-benefit indications by more than 80% and shift prescribing away from ESMO-MCBS grade 1 and 2 indications without reducing use of grade 4 and 5 treatments.
- Rationale: The scales are public, peer-reviewed and updated; using them costs a payer nothing and is more defensible than proprietary criteria.
- Proposed test: A payer pilot applying value tiers to checkpoint inhibitor and targeted therapy indications, measuring approvals, prescribing by grade, spend and appeals.
- Maturity: early-clinical
- Actor: payer

## Sources

- ESMO-MCBS: https://www.esmo.org/guidelines/esmo-mcbs
- ICER: https://icer.org/

## Connected records

- institutions: [American Society of Clinical Oncology (ASCO)](https://onco.cc/institutions/asco/), [European Society for Medical Oncology (ESMO)](https://onco.cc/institutions/esmo/)
- terms: [ICER and health technology assessment](https://onco.cc/terms/icer-value-assessment/)
- bottlenecks: [Incentives reward me-too drugs and marginal gains](https://onco.cc/bottlenecks/b-incentive-misalignment/), [Knowledge reaches practice too slowly](https://onco.cc/bottlenecks/b-knowledge-diffusion/), [Prices and value](https://onco.cc/bottlenecks/b-drug-pricing/)

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