The increase in oral oncolytics has fueled an increase in oncologist dispensing of drugs either from the physician office or from a pharmacy owned by the practice or hospital, as allowed by state laws. Direct dispensing enables physicians to more comprehensively manage their patients’ medical and therapeutic needs, which can facilitate quicker access to drugs and improve compliance. However, according to 2016 Decision Resources Group research,MCOs are concerned about this trend because it diverts prescriptions from their or their pharmacy benefit manager’s contracted specialty pharmacies and provides an additional revenue stream for the oncology practice. New 2017 data and analysis shed further light on the trend. Understanding physician dispensing and its effect on payer reimbursement and oncologists’ prescribing habits is vital to creating a sound market access strategy for drugs to treat renal cell carcinoma and other cancers with oral options.

QUESTIONS ANSWERED

  • How common is it for oncologists to dispense oral RCC drugs from within their practices or by using in-house dispensing pharmacies?
  • For what reasons would physicians want to bypass MCO-directed pharmacies and use a provider-owned pharmacy or dispense from their offices?
  • How do MCOs view and react to in-office dispensing by physicians, and how does this dynamic affect physician reimbursement?
  • Are oncologists more likely to choose oral RCC therapies if they can stock and dispense them instead of going through a payer’s specialty pharmacy?

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

  • Renal Cell Carcinoma - Access & Reimbursement - Detailed, Expanded Analysis: Implications Of Physician Dispensing Of Oral Oncolytics For Renal Cell Carcinoma (US)
    • Market Access Overview
      • Actionable Recommendations to Optimize Market Access
        • Key Stakeholders in the Road to Market Access
          • Stakeholder Influence on Physician Prescribing
          • United States: Stakeholder Dynamics in the Road to Reimbursement
          • Healthcare Coverage in the United States
          • Healthcare Coverage in United States
          • Major Commercial Insurers in the United States
        • Successes and Stumbles
          • Successes Among Renal Cell Carcinoma Therapies in the United States: Physicians
          • Stumbles Among Renal Cell Carcinoma Therapies in the United States: Physicians
          • Oncologist-Reported Best-Performing First-Line Renal Cell Carcinoma Drugs on Market Access Factors
          • Oncologist-Reported Best-Performing Second-Line Renal Cell Carcinoma Drugs on Market Access Factors
          • Successes Among Renal Cell Carcinoma Therapies in the United States: MCOs
          • Stumbles Among Renal Cell Carcinoma Therapies in the United States: MCOs
        • Key Market Access Roadblocks
          • Reimbursement Dynamics
            • United States: Commercial Managed Care Organizations
              • Lessons Learned and Key Takeaways
              • Reimbursement of Key Therapies Treating Renal Cell Carcinoma
              • Reimbursement of Key Therapies Treating Renal Cell Carcinoma in 12 Months
              • Pricing and Reimbursement Drivers
              • Key Findings: Pricing & Reimbursement
              • Most Influential Clinical Factors in Formulary Decisions for Renal Cell Carcinoma Drugs
              • Most Influential Economic and Other Factors in Formulary Decisions for Renal Cell Carcinoma Drugs
              • Types of Contracting Agreements Cited by MCOs for Renal Cell Carcinoma Drugs
              • Cost Sharing for Key Therapies Treating Renal Cell Carcinoma
              • Cost Sharing Incentives to Use Preferred Drugs
              • Average Copay Differential Between Preferred and Nonpreferred Branded Tiers
              • Average Coinsurance for Nonpreferred Branded Drugs
              • Average Copay for Preferred Branded Drugs
              • Copay and Coinsurance Rates for Renal Cell Carcinoma Specialty Drugs
              • Restrictions Affecting Treatment of Renal Cell Carcinoma
              • Restrictions Used in Commercial Plans
              • Prior Authorization Requirements
              • Key Findings
              • MCO Allowance of Physician Dispensing of Oral Oncology Drugs
              • Renal Cell Carcinoma Drugs That MCOs Allow Physicians to Dispense from the Office
              • MCO Allowance for Subsequent Refills on Physician-Dispensed Renal Cell Carcinoma Drugs
              • MCO Actions to Address Physician Dispensing of Oral Oncolytics
          • Pricing and Reimbursement, Policy, and Coverage: Impact on Prescribing
            • Patient Share in Key Payer Channel
              • Key Findings
              • Patient Share for Renal Cell Carcinoma Drugs Among Commercially Insured Patients with Advanced/Metastatic Disease
              • Treatment Decision Drivers
              • Factors Affecting Choice of Renal Cell Carcinoma Therapies
            • Prescriber Preference
              • Prescriber Preferences for Renal Cell Carcinoma
              • Impact of Payer Strategies on Oncologist Prescribing of Renal Cell Carcinoma Therapies in the First Line
              • Impact of Payer Strategies on Oncologist Prescribing of Renal Cell Carcinoma Therapies in the Second Line
            • Impact of Restrictions and Physician Dispensing on Prescribing
              • Impact of Payer Controls on Prescribing: Key Findings
              • Oncologist-Reported Most Restrictive Payer Controls on Renal Cell Carcinoma Drugs
            • Implications of Physician Dispensing: Oncologists
              • Key Findings
              • Oncologist Practice Capability for Physician Dispensing
              • Frequency of Oncologists' Dispensing of Branded Oral Renal Cell Carcinoma Drugs
              • Oncologist-Reported Frequency of Dispensing Subsequent Fills
              • Impact of Physician Dispensing of Oral Oncolytics on IV Therapies
              • Oncologist-Reported Actions MCOs Have Taken in Response to Physician Dispensing
          • Market Access Landscape for Emerging Therapies
            • Impact of Emerging Therapies on Prescribing
              • Likely Impact of Emerging Therapies for Renal Cell Carcinoma
              • Restrictions Oncologists Expect to Encounter on New Combination Therapies
              • Expected Patient Shares for Renal Cell Carcinoma Drugs in 2019 Depending on Payer Restrictions
            • Potential Reimbursement of Emerging Combination Therapies
              • Key Findings
              • MCOs' Expected Reimbursement of Opdivo + Yervoy for First-Line Renal Cell Carcinoma
              • MCOs' Expected Reimbursement of Bavencio + Inlyta for First-Line Renal Cell Carcinoma
              • MCOs' Expected Management of the Expense of Combination Therapies for Renal Cell Carcinoma
              • MCOs' Expected Utilization Management Controls for Combination Therapies for Renal Cell Carcinoma
            • Prescriber and MCO Priorities for Emerging Therapy Evaluation
              • Key Findings
              • Areas of Future Opportunity for Renal Cell Carcinoma: MCOs
              • Areas of Future Opportunity for Renal Carcinoma Cell: Physicians
          • Methodology
            • Primary Market Research Methodology: Physicians
              • Average Number of Years Practiced Post-Residency
              • Average Number of Renal Cell Carcinoma Patients Under Management
              • Renal Cell Carcinoma Drugs Prescribed by Surveyed Oncologists
              • Distribution of Medical Practices by Region
              • Distribution of Medical Practices by State
              • Surveyed Oncologists' Practice Setting
              • Insurance Coverage of Surveyed Oncologists' Cancer Patients
            • Primary Market Research Methodology: MCOs
              • Percentage of MCO PDs vs. MDs
              • Distribution of MCOs by Region
              • Distribution of MCO Respondents by State
              • Operations of MCOs: National, Regional, or Single State
              • Plan Types Offered by Surveyed MCOs
              • Range of Number of Lives Served by MCOs
              • Average Number of Lives Managed by Surveyed MCOs
          • Appendix
            • Physician Survey
              • Type of Practice of Office-Based Oncologists
              • Size of Oncologists' Locally Owned Practices
              • Oncology Practices' Use of Group Purchasing Organizations and Buying Consortiums
              • Distribution Channels Used for Renal Cell Carcinoma Drugs
              • Renal Cell Carcinoma Drugs Available for In-House Physician Dispensing
              • Number of MCO Contracts for Physician Dispensing
              • Practices' Encouragement of In-House Physician Dispensing
              • Practices' Incentives to Encourage Physician Dispensing
              • Advantages of Physician Dispensing of Oral Oncolytics
              • Services Provided by Practices' Licensed Pharmacies
              • Margins on Physician-Dispensed Drugs
              • Oncology Practice Collection of Rebates on Physician-Dispensed Drugs
              • Economic Value of Physician Dispensing
              • Payer Challenges Encountered by Oncologists Dispensing Oral Oncology Drugs
              • Impact of On-Site Dispensing of Oral vs. IV Therapies
              • Reasons Oncologists Are More Likely to Dispense Oral than IV Therapies
              • Years' Experience with Physician Dispensing of Oral Oncology Drugs
              • Anticipated Change in Physician Dispensing of Oral Oncology Drugs
              • Indications for Which Oncologists Engage in Physician Dispensing
              • Reasons Practices Do Not Engage in Physician Dispensing
              • Best-Performing First-Line Renal Cell Carcinoma Drugs on Clinical Factors
              • Best-Performing Second-Line Renal Cell Carcinoma Drugs on Clinical Factors
              • Oncologists' Likelihood of Prescribing Opdivo + Yervoy Combination
              • Prescribing Potential for Bavencio + Inlyta for First-Line Advanced/Metastatic Renal Cell Carcinoma
              • Reasons Why Oncologists Would Not Prescribe Opdivo + Yervoy
              • Factors Holding Back 'Very Likely' Prescribing of Opdivo + Yervoy
              • Oncologists' Anticipated Method of Prescribing Opdivo + Yervoy
              • Oncologists' Expectations of Patient Cost Sharing of Opdivo + Yervoy
              • Reasons Oncologists Would Not Prescribe Bavencio + Inlyta Combination
              • Factors Holding Back 'Very Likely' Prescribing of Bavencio + Inlyta
              • Oncologists' Anticipated Method of Prescribing Bavencio + Inlyta
            • MCO Survey
              • Control of Formulary Development and Contracting
              • MCO Use of Standard vs. Custom Pharmacy Benefits Manager Formularies
              • Influence of MCO P&T Committee Members
              • Items Needed for P&T Formulary Review of Renal Cell Carcinoma Drugs
              • Timing of P&T Committee Formulary Reviews and Utilization Management Decisions on Renal Cell Carcinoma Drugs
              • Use of Preferred/Nonpreferred Tiers for Traditional and Specialty Drugs
              • Percentage of MCOs Switching to Preferred/Nonpreferred Tiers in 12 Months
              • Coverage of Renal Cell Carcinoma Drugs Under Both Pharmacy and Medical Benefits
              • Determiners of Coverage Under the Pharmacy or Medical Benefits
              • Average Coinsurance for Drugs Covered Under the Specialty Tier
              • Average Copay for Drugs Covered Under the Specialty Tier
              • MCO-Imposed Controls on Renal Cell Carcinoma Drugs
              • Out-of-Pocket Spending Caps on Renal Cell Carcinoma Drugs
              • Type of Specialty Pharmacy Used by MCOs
              • Openness of MCOs' Specialty Networks
              • Specialty Pharmacy Services
              • Extent of Mandatory Specialty Pharmacy Use for Renal Cell Carcinoma Drugs
              • Entity Driving Mandatory Specialty Pharmacy Use
              • Percentage of MCOs Requiring Physician Dispensing Through Licensed Pharmacies
              • MCO-Reported Change in Physician Dispensing Over Three Years
              • Reasons MCOs Do Not Contract for Physician Dispensing
              • Billing Method Used for Office-Dispensed Oral Oncology Drugs
              • Coding Required for Reimbursement of Office-Dispensed Products
              • Basis for Medical Claim Billing of Office-Dispensed Products
              • Use of Average Wholesale Price as a Basis for Pharmacy-Adjudicated Products
              • MCO Level of Concern About Physician Dispensing of Oral Oncolytics
              • MCOs' Main Concerns About Physician Dispensing
              • Consequences of Diverting Oral Oncolytics from PBMs' Specialty Pharmacies
              • Other MCO Strategies to Control the Expense of Combination Therapies
              • Most Compelling Types of Pharmacoeconomic Data
              • Therapies for which Pharmacoeconomic Data was Submitted to MCOs
              • Quality of Submitted Pharmacoeconomic Data
              • Value Assessment Models Used by MCOs for New Renal Cell Carcinoma Therapies
              • Future Pursuit of Risk-Based Contracts for Renal Cell Carcinoma Drugs
              • MCO Preferred Comparators in Clinical Trials for Emerging Renal Cell Carcinoma Therapies

        Author(s): Chris Lewis

        Chris Lewis serves as primary research manager, U.S. Access and Reimbursement, with responsibility for coordination, content review and content generation of the market access and reimbursement insights at DRG. Content is based on online surveys of managed care organizations and physicians and expert analysis of reimbursement and prescribing patterns of key therapies treating various disease states.

        Lewis was an analyst/senior analyst for the group’s HealthLeaders-InterStudy subsidiary for eight years, specializing in the managed care and pharmacy benefit management industries. Throughout her tenure, she has produced the Health Plan Analysis reports for California, New York, New Jersey, Connecticut, and Pennsylvania and authored DRG’s series of pharmacy benefit manager profiles. She has also conducted numerous webinars for the group. She is a seasoned journalist with a B.A. in communications from California State University, Sacramento.


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