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Formulary Advantages in Orally Delivered Oncology Agents: Impact of Cost Controls and Emerging Agents on Key Brands
Decision Resources, Inc., Dec 2009, Pages: 133
Orally delivered agents to treat cancer include targeted and chemotherapeutic agents, most of which compete directly with intravenously (IV) administered agents, and are priced similarly. Furthermore, choosing an oral oncology treatment over an IV treatment does not necessarily mean a reduction in per patient hospital costs, since many agents are part of multi-agent treatment regimens that include IV drugs.
The fact that U.S. sales of orally delivered oncology drugs exceeded $5 billion in 2008 would seem to make these drugs a good target for cost reduction by payers, but limited treatment options and the severity of the disease make rigorous cost controls difficult to implement. Instead, payers are increasingly looking to shift a greater percentage of the treatment cost back to the patient.
Using tiering and restrictions data from Fingertip Formulary, as well as insight from 50 pharmacy directors, this report determines the key trends in reimbursement of orally delivered oncology treatments, drivers of these trends, and how stakeholders can capitalize on future shifts in coverage to steal share from the competition.
Questions answered in this report:
- Commercial health plans are far more likely to reimburse and/or offer more favorable tier placement for orally delivered cancer treatments than Medicare plans. What are the most common tier placements for orally delivered cancer treatments? What agents are the most likely to receive advantaged tier placement? What agents are not covered by the majority of Medicare plans? What are the most commonly cited reasons for lack of coverage? What restrictions are used to control costs?
- Most health plans cover orally delivered cancer agents through their pharmacy benefits with an associated co-payment. What is the current average co-payment associated with orally delivered cancer drugs? How will co-payments change over the next five years? What is the average coinsurance payment percentage for orally delivered cancer agents? How will coinsurance percentage payments shift over the next five years? How do beneficiary obligations differ between national, regional, and single state plans?
- Nine new orally delivered cancer agents are expected to launch within the next five years. How have newly launched orally delivered cancer agents been incorporated into health plans? What is the average time to review for newly launched cancer agents? How do surveyed pharmacy directors expect emerging agents will be covered in their health plans? What will be the expected co-payments and/or coinsurance?
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