Background: According to the National Institutes of Health, medical expenditures are projected to reach $158 billion by the year 2020. This represents a 27% increase from 2010 costs. Prostate cancer is in the top 5 contributors of this cost, and is projected to reach $12 billion. Advancements in drugs, surgery, and radiation therapy have all contributed to an increase in costs. Payers are feeling increased pressure to make cost-effective choices among these agents.
Objective: To assess how payers are currently managing the biologic agents for prostate cancer. Methods: The Zitter Group collected and evaluated payer policies from 202 commercial payers representing 183.7 million lives. The payer policies were entered into a database based on strict rules of entry and interpretation. Each payer policy for Zytiga, Provenge, Jevtana, and Xtandi were categorized into 6 categories: drug covered without a prior authorization (PA), PA required no criteria, managed to the prescribing information (PI) with off-label indications, managed to the PI, managed more than PI, and not covered. Payer policies were evaluated over a period of 2 years.
Results: More than 80% of all commercial payers require PA for most drugs in the category. Although Xtandi’s policies are still developing after its recent approval, it appears that payers will be managing it with PA as well. Most payers manage the drugs to their labels, articulating lines of therapy, and concomitant therapies, with larger payers more likely than smaller payers to have robust policies articulating full label indication statements. Two payers manage Provenge with guidelines more strictly than label, whereas 1 payer does the same with Zytiga.
Conclusions: Most payers are still managing prostate cancer agents to their labels. However, some sequencing of agents is occurring based on the differences in first-line and second-line agents’ labels. This is likely short-term until Xtandi receives approval as a first-line agent.
