Payers Report an Increase in Use of Genomic Markers

Therapies for chronic conditions are increasingly being subjected to utilization management tools, according to ICORE Healthcare's 2011 Medical Pharmacy & Oncology Trend Report.

Therapies for chronic conditions are increasingly being subjected to utilization management tools, according to ICORE Healthcare’s 2011 Medical Pharmacy & Oncology Trend Report.

Genomic markers will continue to be an increasingly important tool to match the therapeutic effect of a specialty medication with a patient’s genomic information, according to the research included in the second edition of ICORE Healthcare’s 2011 Medical Pharmacy & Oncology Trend Report.

To determine positive treatment outcomes, many health plans have already structured their benefit design to require genomic testing. According to the ICORE report, 6 in 10 members are subject to an Oncotype DX test before chemotherapy. HER2 testing in advance of breast cancer therapy and KRAS testing in advance of colorectal cancer are also the norm for 4 of every 5 members across health plans. If receiving therapy for HIV, 1 in 3 patients are required to undergo a test for CD4 count. According to ICORE numbers, the number of lives required to undergo genomic tests increased. For example, from 2010 to 2011, there was an increase in the use of Oncotype DX from 56% to 60% lives, and the use of tests measuring CD4 count increased 32%.

Common utilization methods employed by payers include:

  • Prior authorization
  • The National Comprehensive Cancer Network guideline adherence
  • Step therapy, or using the safest and cost-effective therapy first
  • Genetic tests prior to initial therapy
  • Post-claims edits for appropriate diagnosis
  • Retrospective drug utilization review, which is a comprehensive review of patients' prescription and medication data before, during, and after dispensing to minimize inappropriate prescribing

The ICORE report noted that many payers are contemplating coverage rules for breast cancer susceptibility genes and epidermal growth factor receptor. With more than 100 agents for breast cancer in the pipeline in either phase 2 or phase 3 trials, the report predicts an uptick in the use of these tools to gauge the therapeutic effect of new drugs entering the marketplace.