Oncology Reimbursement: 2011-2012

 Report Table of Contents

  • Plan Demographics
    • Methodology
    • Demographics of participating plans
    • Co-insurance/co-pay structure of participating plans
  • Oncology Management
    • Use/perception of NCCN guidelines
    • Highest-cost cancer indications to plans
    • Most prevalent cost-monitoring methodologies
    • Trends in specialty pharmacy utilization
    • Price threshold for specialty tier placement
    • Oncologists’ response to lower reimbursement rates
    • Effect of UnitedHealth Group’s change in reimbursement policy
    • Most influential endpoints when evaluating cancer therapies for coverage
    • Payer preference of oral vs. infused oncologics
  • Healthcare Reform
    • Most impactful aspects of Healthcare Reform on oncology management
    • Impact of CER on cost controls in oncology
  • Accountable Care Organizations (ACOs)
    • Payer impressions of ACOs
    • Payer likelihood to form or partner with an ACO in oncology
    • Primary drivers for payer formation of ACOs
    • Main areas of expected cost reduction through ACOs
    • Key design elements of ACOs
    • The overall expected savings from ACOs in oncology
    • Greatest expected challenges of ACOs
    • Key roles of manufacturers in the ACO-payer partnership
  • Patient Centered Medical Homes (PCMHs)
    • Likelihood of payer creation of PCMHs
    • Primary drivers behind PCMHs creation
  • Quality Initiatives
    • The types of quality initiatives expected in oncology
    • Impact of quality initiatives on oncology management
    • Incentive structure of quality initiatives
  • Diagnostics and Biomarkers
    • Most influential guidelines for diagnostic test coverage
    • Cancer indication that receives the most reimbursement for genetic tests
    • Payer perceived primary benefits of genetic tests
    • Level of clinical benefit needed for diagnostic test to be reimbursed
    • Most common reimbursement approach for genetic tests
  • Breast Cancer
    • Level of clinical benefit expected from a new breast cancer drug
    • Most influential patient characteristics on breast cancer management
    • Requirements for and coverage of HER2 testing
    • Coverage for Herceptin and Tykerb
    • Use of Avastin in breast cancer
    • Payer perception of the latest clinical data of exemestane in high-risk post-menopausal women
    • Potential restrictions for exemestane
    • Payer perception of the latest clinical data of pipeline agents trastuzumab-DM1, neratinib, pertuzumab, eribulin and denosumab
    • Expected placement of the pipeline agents into the treatment paradigm
    • Expected pricing of the pipeline agents
  • Metastatic Melanoma
    • Payer perception of Yervoy’s price
    • Current management of Yervoy
    • Response to the most recent survival data for Yervoy
    • Payer perception of the most recent clinical data of pipeline agents vemurafenib and GSK436/GSK212
    • Potential coverage of pipeline agents
    • Payers’ desires for efficacy in metastatic melanoma agents
    • Coverage and reimbursement for BRAF companion diagnostic test
    • Payer perception of a fair price for BRAF companion diagnostic
  • NSCLC
    • Level of concern NSCLC represents to payers
    • Level of clinical benefit expected from a new NSCLC drug
    • Most important patient characteristics in NSCLC management
    • Coverage of Tarceva and Tarceva/Avastin combination in NSCLC
    • Coverage of Herceptin and platinum-based chemotherapy
    • Coverage of combination use of Cisplatin, Alimta and Avastin
    • Payer perception of the latest clinical data of pipeline agents Astuprotimut-R, Emepepimut-S, Crizotinib, and MetMAb
    • Expected placement of the pipeline agents into the treatment paradigm
    • Expected pricing of pipeline agents
    • Payer perception of the EURTAC trial
    • Payer perception of using Tarceva as a 1st line single agent in EGFR+ patients
  • Multiple Myeloma
    • Level of concern multiple myeloma represents to payers
    • Level of clinical benefit expected from a new multiple myeloma agent
    • Willingness to restrict access to multiple myeloma treatments in the next 3 years
    • Awareness of Velcade recent survival data
    • Current Revlimid management
    • Payer perception of cytogenetic testing
    • Level of payer concern over Revlimid’s safety
    • Preference of Revlimid vs. Velcade for maintenance therapy
    • Payer perception of the latest clinical data of pipeline agent pomalidomide
    • Expected price for pomalidomide
  • Non-Hodgkin’s Lymphoma (NHL)
    • Level of concern NHL represents to payers
    • Coverage of Treanda/Rituxan combination as 1st line in follicular lymphoma
    • Coverage of Rituxan as maintenance therapy in NHL
    • Payer perception of radioimmunotherapy utilization and place in the treatment paradigm
    • Payer perception of NHL therapy utilization in the next 2 years