Private and Medicare plans will continue their receptiveness to oral oncology therapies over the next five years, but anticipated increases in coinsurance rates and copays will shift more of the cost burden to beneficiaries. An analysis of commercial and Medicare plans’ formulary treatment of solid-tumor and hematological tumor therapies shows that payers within different channels follow divergent tiering strategies. For breast cancer and other solid-tumor cancer therapies, commercial plans are more likely to cover the therapies on an advantaged tier, while larger-than-average plans remain the most favorable to these therapies across both channels. This trend has benefited emerging therapies such as GlaxoSmithKline’s Votrient (pazopanib), which launched in the summer of 2010 and now enjoys favorable tiering on 48% of plans. Meanwhile, the rise of a generic version of AstraZeneca’s Arimidex (anastrozole) will make the breast cancer market more challenging as drug marketers increasingly must find justification for charging branded therapy prices.

For emerging therapies, health plans appear mostly receptive and will likely cover these newer treatments as a pharmacy benefit. However, these plans are interested in new drugs’ data regarding overall survival and progression-free survival, which could drive tiering strategies for these new therapies. In addition to quality data, marketers of these emerging therapies must consider prices for their products, as surveyed plans report that oral agents used in oncology represent a disproportionately growing percentage of their prescription drug spending. Three emerging therapies surveyed – Boeringer Ingelheim’s Tovok (BIBW-2992), Pfizer’s axitinib and Pfizer’s neratinib – will enter a marketplace that features multiple brands already entrenched on Tier 1 or 2. In order to obtain comparable formulary coverage, surveyed results show that these therapies must be priced competitively with existing products while also offering comparable or better outcomes measures.

Using tiering and restrictions data from Fingertip Formulary, as well as insight from 44 pharmacy directors, this report determines the key trends in reimbursement of oral oncology therapies, drivers of these trends, and how stakeholders can capitalize on future shifts in coverage to steal share from the competition.


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