November 2015 Edition Vol.11, Issue 11

Evidence Development and Payer Risk: Planning the Route to Market Access

Evidence Development and Payer Risk: Planning the Route to Market Access (continued)

Even in the U.S., payer management beyond a prior authorization for a labeled indication is growing. For example, in the increasingly crowded market of multiple myeloma, around one-third of community oncologists reported an increase in payers asking them to change their prescribing for Revlimid® (lenalidomide, Celgene), Velcade® (bortezomib, Millennium/Takeda) and Pomalyst® (pomalidomide, Celgene), in particular.2 Reasons for these requests varied, but step edits and pathways are certainly evidence of increased payer management of this category (Figure 1). In addition, a sample of plans operating on the national, regional and state levels indicates that differential tiering is also being leveraged to manage products differentially. In fact, around one-third of patients across payer types are being affected by this type of management, and smaller plans operating within a region and in a single state are the most likely to manage in this way (Figure 2).

In addition, payers may leverage pathways that may exclude products with less-than-compelling value propositions. For instance, UnitedHealthcare/Anthem’s AIM Cancer Care Quality Program currently excludes Pfizer’s Ibrance® (palbociclib), which received accelerated approval based on its Phase II PALOMA-1 trial.3 Even though Ibrance nearly doubled progression-free survival in hormone receptor-positive breast cancer, the pathway may be waiting for more mature overall survival data to support the product’s additional value commensurate with its cost of nearly $10,000 more per month than its comparator, letrozole. 

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