Expansion of Prior Authorization Policies for Oncology Agents

Facing new agents and rising costs, payers continue to tighten their management of oncology.

Facing new agents and rising costs, payers continue to tighten their management of oncology.

Payers continue to increase the rate of prior authorizations for oncology agents in the face of ever-increasing costs. Breast, lung, and colon and rectal cancers have remained payers’ top management priorities over the past several years. Given their better understanding of solid tumors in terms of treatment pathways, payers are more comfortable controlling these cancer subtypes.

Tracking the restrictiveness of prior authorizations for oncology, particularly for breast, lung, and colon and rectal cancers, may serve as indicators of things to come in terms of payer management for other oncology subtypes. One-third of covered commercial lives are managed by plans with fully developed prior authorization (PA) policies for a majority of breast cancer agents. Management beyond following product insert guidelines remains minimal however, and limitations on cancer type and line of therapy typically mirror label specifications. That said, some smaller payers have enacted line of therapy limitations more restrictive than label for Halaven, Herceptin, and Tykerb in the treatment of breast cancer. With two oral breast cancer treatments on the market, commercial payers are also utilizing patient cost sharing to curb some of the expense associated with this high profile indication.

Similar to their management of breast cancer, payers are increasing the prevalence of prior authorizations affecting non-small cell lung cancer (NSCLC) agents. However, like with breast cancer, a majority of payers continue to focus PAs for NSCLC on limiting inappropriate utilization. Currently only two payers manage Alimta or Tarceva more strictly than product insert guidelines, and a plurality of commercial payers has criteria that is less restrictive than the NSCLC agents’ FDA approved indications, not specifying line of therapy or concomitant mandates in policy language. Limitations on cancer type and line of therapy for lung cancer treatments also reflect the product label as payers tend to allow physicians substantial control of patient care given the complexity of treating NSCLC patients. Although payers have been more reserved in their line of therapy restrictions for NSCLC, use of controls such as limitations on concomitant use and recycling are expected to expand. As with the oral agents facing cost sharing requirements for breast cancer, payers are also applying higher cost sharing burdens to the oral agent Tarceva for NSCLC treatment.

These findings come from The Zitter Group’s Prior Authorization Tracking Tool, a detailed database of health plan prior authorization policies for more than 450 commercial and government payers. Other key highlights from the most recent reports on oncology include:

  • Over half of covered commercial lives are managed by plans with fully developed colorectal cancer policies for most of the agents in the category; however no commercial payers currently manage colorectal cancer agents more strictly than label
  • In efforts to hinder improper use of colorectal cancer agents, several commercial and Managed Medicare payers have placed prohibitions on concurrent treatment with other targeted therapies
  • Payers are beginning to place limitations on recycling of colorectal cancer agents as a way to prevent physicians from reusing an agent following disease progression
  • Payers are starting to address Zelboraf’s new indication, and over 40% of commercial covered lives are managed by plans with a fully developed melanoma policy for Zelboraf
  • Commercial payers have continued to increase management of chronic myelogenous leukemia (CML) treatments over the past six months and over 67% of lives are now covered by payers who place a prior authorization on all drugs in the category
  • More so than commercial payers, over 80% of Managed Medicare payers cover oral CML agents on a specialty tier, increasing the patient cost sharing burden
  • Approximately 70% of plans now manage prostate cancer agents with a prior authorization, and larger plans are generally further along in the management continuum
  • Payers have placed minimal restrictions on multiple myeloma agents and off-label use is commonly allowed, particularly for the oral agents.

SOURCE: The Zitter Group