Immune checkpoint inhibitors have revolutionized the treatment of multiple oncology indications but the high costs associated with these agents present significant challenges for payers. The potential for label expansions into additional indications and combinatorial approaches involving immune checkpoint inhibitors will put further pressure on MCO commercial plans. Developing a clear understanding of the reimbursement landscape and effect on prescribing is critical for maximizing commercialization of immune checkpoint inhibitors. This content examines the current and future reimbursement dynamics for immune checkpoint inhibitors in the United States with a focus on key indications— malignant melanoma, bladder cancer, and squamous cell carcinoma of the head and neck (SCCHN).

Questions Answered:

  • What role do immune checkpoint inhibitors play in the treatment of oncology indications such as malignant melanoma, bladder cancer, and SCCHN? In what treatment settings are they mostly prescribed?
  • How broadly do MCOs cover immune checkpoint inhibitors on their formularies and what kind of restrictions do they use to control usage? Do access and reimbursement challenges for immune checkpoint inhibitors differ by indication?
  • Do payers believe the efficacy of the immune checkpoint inhibitors justifies their cost, and which drug do they think performs the best on clinical and other attributes?
  • What are physicians’ views on emerging immune checkpoint inhibitors in late-stage development ? How do clinicians expect prescribing to change in the future, and what factors, if any, will drive these changes?

Product Description

Access & Reimbursement: Provides in-depth insight regarding the impact of payer policy on physician prescribing behavior so you can build your market access strategy and optimize your brand positioning.

Table of contents

  • Immune Checkpoint Inhibitors - Access & Reimbursement - Detailed, Expanded Analysis (US)
    • Market Access Overview
      • Actionable Recommendations to Optimize Market Access
        • Successes and Stumbles
          • Overview of Successes & Stumbles for Immune Checkpoint Inhibitors
          • Successes Among Immune Checkpoint Inhibitors in the United States: Physicians
          • Stumbles Among Immune Checkpoint Inhibitors in the United States: Physicians
          • Top-Performing Immune Checkpoint Inhibitor for Market Access Factors in Malignant Melanoma
          • Top-Performing Immune Checkpoint Inhibitor for Market Access Factors in Bladder Cancer
          • Top-Performing Immune Checkpoint Inhibitor for Market Access Factors in SCCHN
          • Successes Among Immune Checkpoint Inhibitors in the United States: MCOs
          • Stumbles Among Immune Checkpoint Inhibitors in the United States: MCOs
        • Key Stakeholders in the Road to Market Access
          • Stakeholder Influence on Oncologist Prescribing of Immune Checkpoint Inhibitors
          • United States: Stakeholder Dynamics in the Road to Reimbursement
          • Healthcare Coverage in the United States
          • Healthcare Coverage in the United States
          • Major Commercial Insurers in the United States
        • Key Market Access Roadblocks
          • Reimbursement Dynamics
            • United States: Commercial Managed Care Organizations
              • Lessons Learned and Key Takeaways
              • Current Coverage Status of Immune Checkpoint Inhibitors by Commercial Plans
              • Future Reimbursement of Immune Checkpoint Inhibitors by Commercial Plans in 12 Months' Time
              • Pricing and Reimbursement Drivers
              • Key Findings: P&R
              • Factors Influencing Formulary Placement or Reimbursement
              • Value Assessment and Pharmacoeconomics
              • Preferred Pharmacoeconomic Models for Reimbursement of Immune Checkpoint Inhibitors
              • Cost-Sharing for Key Immune Checkpoint Inhibitors
              • Copay and Coinsurance Rates for Immune Checkpoint Inhibitors in Specialty Tier
              • Restrictions Affecting Immune Checkpoint Inhibitors
              • Restrictions Used in Commercial Plans
              • Utilization Management Controls for Immune Checkpoint Inhibitors in Malignant Melanoma
              • Utilization Management Controls for Immune Checkpoint Inhibitors in Bladder Cancer
              • Utilization Management Controls for Immune Checkpoint Inhibitors in SCCHN
          • Pricing and Reimbursement, Policy, and Coverage: Impact on Prescribing
            • Patient Share in Commercially Insured Plans
              • Key Findings for Immune Checkpoint Inhibitors in Malignant Melanoma
              • Patient Share for BRAF-Mutation-Positive Unresectable or Metastatic Malignant Melanoma
              • Patient Share for BRAF-Wild-Type Unresectable or Metastatic Malignant Melanoma
              • Key Findings for Immune Checkpoint Inhibitors in Bladder Cancer
              • Patient Share for Locally Advanced or Metastatic Bladder Cancer
              • Key Findings for Immune Checkpoint Inhibitors in SCCHN
              • Patient Share for Recurrent or Metastatic SCCHN
              • Treatment Decision Drivers
              • Top Prescribing Drivers for Immune Checkpoint Inhibitors in Malignant Melanoma
              • Top Prescribing Drivers for Immune Checkpoint Inhibitors in Bladder Cancer
              • Top Prescribing Drivers for Immune Checkpoint Inhibitors in SCCHN
            • Prescriber Preference
              • Prescriber Preferences in Select Oncology Indications
              • Impact of Payer Strategies on Prescribing for BRAF-Mutation-Positive Malignant Melanoma
              • Impact of Payer Strategies on Prescribing for BRAF-Mutation-Negative Malignant Melanoma
              • Impact of Payer Strategies on Prescribing for Locally Advanced or Metastatic Bladder Cancer
              • Impact of Payer Strategies on Prescribing for Recurrent or Metastatic SCCHN
            • Impact of Restrictions on Prescribing
              • Payer Policy Impact on Prescribing: Key Findings
              • Payer Policy Impact on Prescribing of Immune Checkpoint Inhibitors for Malignant Melanoma: Office
              • Payer Policy Impact on Prescribing of Immune Checkpoint Inhibitors for Malignant Melanoma: Hospital
              • Payer Policy Impact on Prescribing of Immune Checkpoint Inhibitors for Bladder Cancer: Hospital
              • Payer Policy Impact on Prescribing of Immune Checkpoint Inhibitors for Bladder Cancer: Office
              • Payer Policy Impact on Prescribing of Immune Checkpoint Inhibitors for SCCHN: Hospital
              • Payer Policy Impact on Prescribing of Immune Checkpoint Inhibitors for SCCHN: Office
          • Market Access Landscape for Emerging Therapies
            • Impact of Emerging Immune Checkpoint Inhibitors on Prescribing
              • Likely Impact of Emerging Immune Checkpoint Inhibitors for Malignant Melanoma
              • Impact of Tier Placement on Anticipated Prescribing of Tecentriq or PDR001 in Malignant Melanoma in 2020
              • Likely Impact of Emerging Immune Checkpoint Inhibitors for Bladder Cancer
              • Impact of Tier Placement on Anticipated Prescribing of Tremelimumab Plus Imfinzi for Bladder Cancer in 2019
              • Likely Impact of Emerging Immune Checkpoint Inhibitors for SCCHN
              • Impact of Tier Placement Anticipated Prescribing of Imfinzi Plus Tremelimumab for SCCHN in 2019
            • Potential Placement of Emerging Immune Checkpoint Inhibitors at Various Prices
              • Potential Reimbursement of Emerging Immune Checkpoint Inhibitors
              • Expected Commercial MCO Coverage of PDR001 for Untreated BRAF-Mutation-Positive Malignant Melanoma
              • Expected Commercial MCO Coverage of Tremelimumab Plus Imfinzi for Stage IV Urothelial Carcinoma
            • Prescriber and MCO Priorities for Emerging Immune Checkpoint Inhibitors
              • Key Findings
              • Top Five Attributes in the Development of Immune Checkpoint Inhibitors to Treat Bladder Cancer: Physicians
              • Top Five Attributes in the Development of Immune Checkpoint Inhibitors to Treat Malignant Melanoma: Physicians
              • Top Five Attributes in the Development of Immune Checkpoint Inhibitors to Treat SCCHN: Physicians
              • Top Three Attributes in the Development of Immune Checkpoint Inhibitors: MCOs
          • Methodology
            • Primary Market Research Methodology: Physicians
              • Postresidency Practice Experience
              • Average Number of Patients Treated per Month for Malignant Melanoma, Bladder Cancer, and SCCHN
              • Agents Prescribed Outside of a Clinical Trial for Malignant Melanoma, Bladder Cancer, and SCCHN
              • Practice Setting of Surveyed Oncologists
              • Distribution of Medical Practice by Region
              • Distribution of Medical Practice by State: Northeast
              • Insurance Coverage of Malignant Melanoma, Bladder Cancer, and SCCHN Patients
            • Primary Market Research Methodology: MCOs
              • Distribution of MCO Respondents by Job Title
              • Distribution of MCOs by Region
              • Distribution of MCOs by State
              • Operation of MCOs: National, Regional, or Single State
              • Types of Health Plans Offered by MCOs
              • Distribution of MCOs by Number of Covered Lives
              • Average Number of Lives Managed by MCOs
          • Appendix
            • Key Abbreviations Related to Immune Checkpoint Inhibitors
            • Physician Survey
              • Top-Performing Immune Checkpoint Inhibitor for Clinical Factors in Malignant Melanoma
              • Statement Agreement on Use of Opdivo Plus Yervoy for Malignant Melanoma
              • Reasons for Not Prescribing Combination of Tecentriq+Zelboraf+Cotellic in Malignant Melanoma After Launch
              • Reasons for Not Prescribing Combination of PDR001+Tafinlar+Mekinist in Malignant Melanoma After Launch
              • Statement Agreement on Future Prescribing of Triplet Regimens for BRAF-Mutation-Positive Malignant Melanoma
              • Top-Performing Immune Checkpoint Inhibitor for Clinical Factors in Bladder Cancer
              • Percentage of Opdivo, Keytruda, Bavencio, Imfinzi Prescriptions Denied by Insurers for Bladder Cancer
              • Reasons for Denied Opdivo, Keytruda, Bavencio, Imfinzi Prescriptions for Bladder Cancer
              • Statement Agreement on Use of Immune Checkpoint Inhibitors and Clinical Profile for Bladder Cancer
              • Reasons for Not Prescribing Tremelimumab Plus Imfinzi in Bladder Cancer After Launch
              • Willingness to Prescribe Opdivo and Tecentriq for Bladder Cancer
              • Willingness to Re-Treat with an Immune Checkpoint Inhibitor Following Adjuvant Treatment in Bladder Cancer
              • Statement Agreement on Future Prescribing of Immune Checkpoint Inhibitors for Bladder Cancer
              • Top-Performing Immune Checkpoint Inhibitor for Clinical Factors in SCCHN
              • Statement Agreement on Use of Immune Checkpoint Inhibitors and Clinical Profile for SCCHN
              • Reasons for Not Prescribing Imfinzi Plus Tremelimumab in SCCHN After Launch
              • Willingness to Prescribe Imfinzi-, Keytruda-, Opdivo-Based Combinations for Recurrent or Metastatic SCCHN
              • Most Promising Immune Checkpoint Inhibitor Combinatorial Approaches for Recurrent or Metastatic SCCHN
              • Statement Agreement on Future Prescribing of Immune Checkpoint Inhibitors for SCCHN
            • MCO Survey
              • Responsibility of Formulary Development and Pharma Contracting in Surveyed MCOs
              • PBM Formulary Type in Surveyed MCOs
              • Formulary Customization in Surveyed MCOs
              • Pharmacy and Therapeutics Committees in Surveyed MCOs
              • P&T Committee Review Requirements for Immune Checkpoint Inhibitors
              • Review Time for Coverage of New Immune Checkpoint Inhibitors
              • Preferred and Nonpreferred Tiering of Branded and Specialty Drugs
              • Expected Future Preferred and Nonpreferred Tiering of Branded and Specialty Drugs
              • Current Reimbursement of Other Therapies by Commercial Plans
              • Indication-Based Formularies for Tiering of Cancer Drugs
              • Reimbursement Status of Immune Checkpoint Inhibitors in Commercial Plans
              • Cost-Sharing Differentials Between Preferred and Nonpreferred Immune Checkpoint Inhibitors in Nonspecialty Tier
              • Copay Differentials Between Preferred and Nonpreferred Immune Checkpoint Inhibitors in Nonspecialty Tier
              • Coinsurance for Preferred and Nonpreferred Immune Checkpoint Inhibitors in Nonspecialty Tier
              • Copay for Preferred and Nonpreferred Immune Checkpoint Inhibitors in Nonspecialty Tier
              • Coinsurance for Drugs in Specialty Tier
              • Copayment for Drugs in Specialty Tier
              • Prior Authorization Requirements for Immune Checkpoint Inhibitors Approved for Malignant Melanoma in Commercial Plans
              • Prior Authorization Requirements for Immune Checkpoint Inhibitors Approved for Bladder Cancer in Commercial Plans
              • Prior Authorization Requirements for Immune Checkpoint Inhibitors Approved for SCCHN in Commercial Plans
              • Factors Most Associated with Immune Checkpoint Inhibitors in Oncology
              • Highest Accepted Cost per Additional Quality-Adjusted Life Year in Commercial Plans
              • Top-Performing Therapies for Malignant Melanoma According to Surveyed MCOs
              • Expected Future Measures to Control the Cost of Cancer Immunotherapy
              • Current and Future Use of Clinical Pathway Programs for Malignant Melanoma, Bladder Cancer, and SCCHN
              • Expected Compliance Rate for Future Clinical Pathways
              • Strategies to Achieve Expected Compliance Rate for Future Clinical Pathways
              • Utilization Management of Immune Checkpoint Inhibitors in Specialty Tier
              • Expected Re-Evaluation of MCO Coverage of Tecentriq Upon Approval for BRAF-Mutation-Positive Malignant Melanoma
              • Expected Changes to Coverage of Tecentriq After Approval for BRAF-Mutation-Positive Malignant Melanoma
              • Expected Future Measures to Control Cost of Tremelimumab Plus Imfinzi in Stage IV Urothelial Carcinoma
              • Expected Utilization Management Controls for Tremelimumab Plus Imfinzi in Stage IV Urothelial Carcinoma
              • Expected Re-Evaluation of Commercial MCO Coverage of Imfinzi Upon Approval for Relapsed or Refractory SCCHN
              • Expected Changes to Coverage of Imfinzi After Approval for Relapsed or Refractory SCCHN
              • Expected Future Measures to Control Cost of Imfinzi Plus Tremelimumab in Relapsed or Refractory SCCHN
              • Expected Utilization Management Controls for Imfinzi Plus Tremelimumab in Relapsed or Refractory SCCHN

        Author(s): Jorrit Schäfer, M.Sc., Ph.D.

        Jorrit Schäfer, M.Sc., Ph.D., is a business insights analyst at Decision Resources Group. Prior to joining DRG, Dr. Schäfer worked as a postdoctoral research associate at Imperial College London, where he studied the impact of antibiotic stress on RNA repair in bacteria. Dr. Schäfer holds a M.Sc. in molecular medicine and a Ph.D. in molecular cell biology from Imperial College London.