Prostate Cancer | Access & Reimbursement | US | 2021

The many premium-priced hormonal therapies for prostate cancer present a financial burden for payers. Moreover, costs are set to increase with the recent approvals of the LHRH antagonist Orgovyx for hormone-sensitive metastatic prostate cancer and the PARP inhibitors Lynparza and Rubraca for previously treated metastatic castrate-resistant prostate cancer (mCRPC). To control the rising costs of prostate cancer treatment, payers have a toolbox of utilization management strategies, including specialty pharmacy management. Based on data from surveys of 30 MCOs, 50 medical oncologists, and 50 urologists, this report analyzes the reimbursement environment for major prostate cancer therapies in both commercial and Medicare Advantage plans, including the drivers of MCO formulary decisions and the impact of utilization controls on surveyed physicians’ prescribing. We also investigate the potential reimbursement environment for two emerging therapies for mCRPC: Novartis’s PSMA-targeted radioligand Lu-PSMA-617 and Pfizer / Astellas’s Talzenna plus Xtandi.

Questions Answered

• What is the coverage status of the major prostate cancer drugs on MCOs’ largest fully insured commercial plans and Medicare plans, and what are the key drivers behind their status?
• What utilization management strategies do payers used to control the cost of prostate cancer drugs? How do payers respond to in-office dispensing of oral prostate cancer drugs by medical oncologists and urologists?
• Which economic factors most influence MCOs’ placement of prostate cancer drugs on their commercial and Medicare plan formularies? What clinical factors drive physicians’ prescribing of prostate cancer therapies, and how do payer restrictions and other nonclinical factors affect their choice of therapy?
• What clinical factors drive physicians’ prescribing of prostate cancer therapies, and how do payer restrictions and other nonclinical factors affect their choice of therapy?

Content Highlights

Geography: United States.

Primary research: Survey of 31 U.S. urologists and 31 U.S. medical oncologists; survey of 30 U.S. managed care organization (MCO) pharmacy and medical directors (PDs/MDs).

Topics: Reimbursement and contracting; access and prescribing; opportunities and challenges for emerging therapies; disease-specific special topic.

Finger Formulary: Formulary coverage data for prostate cancer therapies by commercial plans covering 162.7 million lives nationally and up to 36 million managed Medicare lives.

Key drugs covered: Zytiga, Xtandi, Erleada, Nubeqa, Firmagon, Orgovyx, Provenge, Xofigo, Jevtana, Lynparza, Rubraca.

Product Description

U.S. Access & Reimbursement provides integrated brand- and disease-level insight on reimbursement dynamics and the impact of U.S. payer policy on physician prescribing behavior in the market access environment, including up-to-date analysis of drug coverage and restriction policies and payer and prescriber perspectives on key marketed drugs and receptivity to emerging therapies.