TABLE 5.
Commercial and Medicare Restrictions on NSCLC and CLL Agents Today and Expected in 3-5 Years
| Number of Payers Who Restrict Agents Today | Number of Lives Today | Number of Payers Expected to Restrict Agents in 3-5 Years | Number of Lives in 3 -5 Years | ||||||
|---|---|---|---|---|---|---|---|---|---|
| n | % | n (millions) | % | n | % | n (millions) | % | ||
| NSCLC: commercial | |||||||||
| Use provider-developed pathways to manage | 1.0 | 5 | 9.0 | 7 | 3.0 | 14 | 15.8 | 13 | |
| Buy-and-bill incentives to influence preference toward generic agents | 0.0 | 0 | 0.0 | 0 | 2.0 | 10 | 11.0 | 9 | |
| Buy-and-bill incentives to influence preference toward branded agents | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | |
| Use of value frameworks (e.g., ASCO or ICER)a | 0.0 | 0 | 0.0 | 0 | 4.0 | 19 | 17.1 | 14 | |
| Enter in risk-sharing agreements with providers using pathways (narrower than NCCN guidelines) to manage | 0.0 | 0 | 0.0 | 0 | 2.0 | 10 | 13.8 | 11 | |
| Clinical pathways for providers, without risk sharing | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | |
| Excluded an agent from formulary/coverage | 0.0 | 0 | 0.0 | 0 | 3.0 | 14 | 8.1 | 7 | |
| Implement step edits that require use of one product over another in the same line of therapy per guidelinesa | 0.0 | 0 | 0.0 | 0 | 3.0 | 14 | 12.3 | 10 | |
| Use management tools such as split fills | 0.0 | 0 | 0.0 | 0 | 2.0 | 10 | 6.8 | 6 | |
| Drive use through tiering differentials for like products (same line of therapy or MOA)a | 0.0 | 0 | 0.0 | 0 | 2.0 | 10 | 10.3 | 8 | |
| Not providing coverage for off-label use (not FDA approved) despite NCCN compendia | 0.0 | 0 | 0.0 | 0 | 1.0 | 5 | 4.8 | 4 | |
| Manage more restrictively than label | 0.0 | 0 | 0.0 | 0 | 1.0 | 5 | 2.0 | 2 | |
| CLL: commercial | |||||||||
| Use provider-developed pathways to manage | 2.0 | 10 | 13.8 | 11 | 2.0 | 10 | 13.8 | 11 | |
| Buy-and-bill incentives to influence preference toward generic agents | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | |
| Buy-and-bill incentives to influence preference toward branded agents | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | |
| Use of value frameworks (e.g., ASCO or ICER) | 0.0 | 0 | 0.0 | 0 | 2.0 | 10 | 13.8 | 11 | |
| Enter into risk-sharing agreements with providers using pathways (narrower than NCCN guidelines) to manage | 0.0 | 0 | 0.0 | 0 | 1.0 | 5 | 9.0 | 7 | |
| Clinical pathways for providers, without risk sharing | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | |
| Excluded an agent from formulary/coverage | 1.0 | 5 | 4.8 | 4 | 1.0 | 5 | 4.8 | 4 | |
| Implement step edits that require use of one product over another in the same line of therapy per guidelines | 0.0 | 0 | 0.0 | 0 | 1.0 | 5 | 4.8 | 4 | |
| Use management tools such as split fills | 1.0 | 5 | 4.8 | 4 | 1.0 | 5 | 4.8 | 4 | |
| Drive use through tiering differentials for like products (same line of therapy or MOA) | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | |
| Not providing coverage for off-label use (not FDA approved) despite NCCN compendia | 1.0 | 5 | 4.8 | 4 | 1.0 | 5 | 4.8 | 4 | |
| Manage more restrictively than label | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | |
| NSCLC: Medicare | |||||||||
| Use provider-developed pathways to manage | 1.0 | 5 | 9.0 | 7 | 3.0 | 14 | 15.8 | 13 | |
| Buy-and-bill incentives to influence preference toward generic agents | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | |
| Buy-and-bill incentives to influence preference toward branded agents | 0.0 | 0 | 0.0 | 0 | 1.0 | 5 | 2.0 | 2 | |
| Use of value frameworks (e.g., ASCO or ICER) | 0.0 | 0 | 0.0 | 0 | 2.0 | 10 | 6.8 | 6 | |
| Enter into risk-sharing agreements with providers using pathways (narrower than NCCN guidelines) to manage | 0.0 | 0 | 0.0 | 0 | 2.0 | 10 | 6.8 | 6 | |
| Clinical pathways for providers, without risk sharing | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | |
| Excluded an agent from formulary/coverage | 0.0 | 0 | 0.0 | 0 | 1.0 | 5 | 1.3 | 1 | |
| Implement step edits that require use of one product over another in the same line of therapy per guidelines | 0.0 | 0 | 0.0 | 0 | 3.0 | 14 | 8.1 | 7 | |
| NSCLC: Medicare | |||||||||
| Use management tools such as split fills | 0.0 | 0 | 0.0 | 0 | 2.0 | 10 | 6.8 | 6 | |
| Drive use through tiering differentials for like products (same line of therapy or MOA) | 0.0 | 0 | 0.0 | 0 | 1.0 | 5 | 1.3 | 1 | |
| Not providing coverage for off-label use (not FDA approved) despite NCCN compendia | 0.0 | 0 | 0.0 | 0 | 1.0 | 5 | 4.8 | 4 | |
| Manage more restrictively than label | 0.0 | 0 | 0.0 | 0 | 1.0 | 5 | 9.0 | 7 | |
| CLL: Medicare | |||||||||
| Use provider-developed pathways to manage | 1.0 | 5 | 9.0 | 7 | 0.0 | 0 | 0.0 | 0 | |
| Buy-and-bill incentives to influence preference toward generic agents | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | |
| Buy-and-bill incentives to influence preference toward branded agents | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | |
| Use of value frame works (e.g., ASCO or ICER) | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | |
| Enter into risk-sharing agreements with providers using pathways (narrower than NCCN guidelines) to manage | 0.0 | 0 | 0.0 | 0 | 1.0 | 5 | 9.0 | 7 | |
| Clinical pathways for providers, without risk sharing | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | |
| Excluded an agent from formulary/coverage | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | |
| Implement step edits that require use of one product over another in the same line of therapy per guidelines | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | |
| Use management tools such as split fills | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | |
| Drive use through tiering differentials for like products (same line of therapy or MOA) | 0.0 | 0 | 0.0 | 0 | 1.0 | 5 | 9.0 | 7 | |
| Not providing coverage for off-label use (not FDA approved) despite NCCN compendia | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | |
| Manage more restrictively than label | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | |
aThere were 14 pharmacy directors and 7 medical directors in our sample. Although the sample was not powered to detect statistically significant differences between medical directors and pharmacy directors, the following differences where 2 or more payers answered differently were noted:
- In 3-5 years, medical directors indicated they are more likely to drive utilization through tiering differentials for like products (same line of therapy or MOA), with 2 medical directors and no pharmacy directors indicating that they expected to use tiering differentials to drive preference.
- Medical directors were more likely to implement step edits that require use of one product over another in the same line of therapy per guidelines in 3-5 years, with 3 medical directors expecting to implement step edits in the future, and no pharmacy directors expecting to use this tool.
- Medical directors were more likely to use value frameworks, with 3 medical directors and 1 pharmacy director expecting to use value frameworks.
ASCO = American Society of Clinical Oncology; CLL = chronic lymphocytic leukemia; FDA = U.S. Food and Drug Administration; ICER = Institute for Clinical and Economic Review; MOA = mechanism of action; NCCN= National Comprehensive Cancer Network; NSCLC = non-small cell lung cancer.