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Key finding: For their indication-specific pricing (ISP) programs, 52% of surveyed MCOs identified phase II/III trial data and post-approval research such as phase IV trials as the most important resources for determining an oncology therapy’s value for a new indication.
Clinical guidelines also feature prominently with 34% of payers citing it as the second-most important resource. Notably, 49% of plans pointed to real-world data as among the top two resources for determining value, reflecting the growing influence RWD has on reimbursement decisions.
Third-party providers of value assessment tools such as those created by the Institute for Clinical and Economic Review and Sloan Kettering are tertiary drivers.
The “so what” for strategists: As the use of ISPs spread in coming years, drug companies seeking to add new indications for their oncology therapies will be forced to demonstrate the drug’s value for that new population.
The availability of RWD and ability of plans to alter tiering based on indication mean that drug companies may not be able to easily leverage favorable reimbursement for one indication to a new indication absent supporting data.
Because of guidelines’ influence on ISP decisions, pharma should work early on ensuring guidelines are updated in light of new data. Moreover, they must understand how their drugs fared in the independent value assessments and how it influences oncologists’ prescribing.
What else matters for payer decisions around renal cell carcinoma and hepatocellular carcinoma treatments, as well as indication-specific pricing?
Key questions answered in the analysis:
- What is the current access and prescribing landscape for renal cell carcinoma and hepatocellular carcinoma as new label expansions create more treatment alternatives?
- What is the future for ISP in oncology and are MCOs employing this strategy now?
- What are or will be the major challenges to varying pricing and/or coverage by indication and how do/will MCOs track diagnosis to implement ISP?
- Do oncologists ever encounter situations where the drugs they prescribe are covered differently by indication, and what is their reaction to this trend?
Markets covered: United States.
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