Key finding: Confronted with the premium price of targeted therapies treating hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2-) metastatic breast cancer, managed care organization (MCO) pharmacy and medical directors surveyed by DRG indicated the most likely strategy they will use is leveraging competition among therapies to drive down net pricing, followed by stricter prescribing controls such as prior authorization. A majority of MCOs are also likely to demand justification of a therapy’s value, or its benefits versus the costs.

The “so what” for decision makers: As new oral targeted therapy options enter the HR+/HER2- breast cancer market by 2020, MCOs will likely use the competition to leverage discounts from manufacturers in exchange for favorable coverage.

Value assessment, cost-effectiveness analysis, and application of real-world evidence have become a key part of payers’ formulary evaluation process for breast cancer therapies.

Drug developers should be prepared to tout their product’s overall value proposition to stand out from the current competition, particularly the efficacious new CDK4/6 inhibitors Ibrance, Kisqali and Verzenio.

What else are payers and oncologists saying about breast cancer access and reimbursement? 

The full HR-Positive/HER2-Negative Breast Cancer (US) | Access & Reimbursement | United States report  answers:

  • What clinical and nonclinical factors drive reimbursement of HR+/HER2- breast cancer therapies among commercial MCOs?
  • How do MCOs use real-world data in breast cancer drug evaluation and what are the most important sources of this data?
  • What kinds of payer restrictions do oncologists encounter when prescribing breast cancer therapies and how are they most likely to respond; whether they persist with the payer to obtain coverage or use another therapy instead.
  • What is the potential patient share for three emerging therapies—taselisib, alpelisib and entinostat—in second-line metastatic HR+/HER2- breast cancer treatment?

Markets covered: United States.

Methodology: Surveyed 101 medical oncologists in the United States and 32 U.S. managed care organization (MCO) pharmacy and medical directors (PDs/MDs).

Key drugs covered: Ibrance, Afinitor, Kisqali, Verzenio, Lynparza, Faslodex, Letrozole, Anastrozole, Exemestane

Key companies mentioned: AstraZeneca, Eli Lilly, Novartis, Pfizer, Roche, Syndax Pharmaceutical


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