Cancer Immunotherapy: Payer Insight

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Publication Date:
October 2015
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Immunotherapies are some of the most promising new weapons in the fight against cancer. But are they promising enough to justify their sky-high prices? Payers aren’t convinced, and say they need better data to make effective market access and reimbursement decisions.

FirstWord’s Payer Insight: Cancer Immunotherapy report explains why. This 111-page report gives you an in-depth account of how 12 leading payers in the US and Europe see the cancer immunotherapy landscape. 

You’ll discover payers’ top concerns, find out how they assess the value of new cancer immunotherapy drugs, and get their candid thoughts on pricing, reimbursement, market access, and what they expect from pharma companies.

The report also includes analyses of 4 leading approved immunotherapies, and 10 pipeline drugs currently in clinical trials.

View: US Payers, EU Payers, Approved drugs, Pipeline drugs

“The financial burden of the prices of these drugs is putting a very high strain on the overall budget for CMS and managed care.” - US Payer

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Answering key questions:

Get answers to key questions about approved and pipeline immunotherapies:

  • Checkpoint Inhibitors: how will competition affect pricing negotiations as late-stage pipeline checkpoint inhibitors come on the market?
  • Cancer Vaccines: how will new market entrants escape the shadow of Provenge—a costly early cancer vaccine that overpromised and underdelivered, leaving payers feeling sceptical?
  • CD19-targeted CAR-T Treatments: with only preliminary data available, how will payers evaluate these new treatments?
  • Combination therapies: how will changes to policy and legislation help payers accommodate complex and extremely costly combination therapies?

Top Takeaways

  • Rising Costs: though promising, cancer immunotherapies are set to increase the already high cost of oncology drugs. Find out how higher costs are straining healthcare systems and challenging payers.
  • Restricted Access: high costs are prompting payers in both the US and EU to restrict access to immunotherapies. Find out why payers expect better data and screening techniques to help identify candidates for immunotherapy treatment.
  • Effect of Health Reforms: in the EU, healthcare reforms are having a big impact on pricing, reimbursement and market access for expensive treatments. In the US “Obamacare” is expected to have a similar effect. Learn how these reforms affect payer decision-making for cancer immunotherapies.
  • Pricing Problems: pharma companies are setting prices for cancer immunotherapies without giving payers the clinical data they need for cost-benefit analyses. Find out how this affects long-term budgeting, and how payers are responding.
  • Risk Sharing Too Complex: without the clinical data they need to properly assess risk-sharing, payers are considering other types of agreements for cancer immunotherapies. Find out what those are and how they affect the way new drugs are brought to market.
  • Payers Demand Data: payers expect pharma companies to justify the high prices they charge for cancer immunotherapy drugs. That means providing more and better clinical data to help payers make reimbursement and access decisions. Find out what kind of data payers want and why.

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Key Issues Explored

  • Costs for cancer treatments are rising, and will continue to rise as regulators approve more immunotherapies. Governments are bearing a larger share of these costs.
  • Payers use a variety of data to evaluate new drugs and make reimbursement and access decisions. The lack of real-world data about the clinical benefits of cancer immunotherapies is a growing challenge.
  • Recent healthcare reforms (e.g., the US’s Obamacare, the UK’s EAMS and Cancer Drugs Fund, Germany’s AMNOG law, France’s law of formal HAS assessment) are having a significant impact on reimbursement and access decisions for cancer immunotherapies.
  • Payers believe that pharma companies do not properly appreciate their budget limitations. Reducing the costs of immunotherapy drugs is a top priority.
  • Bottom line: to justify the high cost of cancer immunotherapies, pharma companies must give payers more and better clinical data. Payers see increasing competition in the immunotherapy space as an opportunity to demand it.

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A report based on expert knowledge

US Payers*

  • Medical Director; Policy, Formulary Management, Managed Care Organisation
  • Chief Medical Officer and Chair of the P&T (Pharmacy and Therapeutics) in charge of Medical and Quality; Managed Care Organisation
  • Pharmacy Director; Community Health Plan
  • National Managing Senior Medical Director; Managed Care Organisation
  • Medical Director; Managed Care Organisation
  • Director of Clinical Pharmacy Services; Pharmacy Benefit Manager

EU Payers*

  • Leading Health Economist (France)
  • Medical Director; Association of Statutory Health Insurance Physicians (Germany)
  • G-BA member (Germany)
  • Chief Pharmacist; Specialist Oncology Hospital (UK)
  • Formulary Pharmacist; large teaching hospital focused on oncology (UK)
  • Transparency Committee Member (France)

* Due to the sensitive nature of the interviews and comments made, respondents requested that their identities remain confidential.

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Get Payer Insights Into

Approved Cancer Immunotherapy Drugs

  • Keytruda (pembrolizumab; Merck & Co.)
  • Opdivo (nivolumab; Bristol-Myers Squibb)
  • Provenge (Sipuleucel-T; Dendreon, now acquired by Valeant)
  • Yervoy (ipilimumab; Bristol-Myers Squibb)

Cancer Immunotherapy Pipeline Drugs
Checkpoint Inhibitors:

  • MEDI4736 (durvalumab; AstraZeneca [MedImmune])
  • MPDL3280A/RG7446 (atezolizumab; Roche, Genentech)
  • CP-675/CP-675,206 (tremelimumab, AstraZeneca)

Cancer Vaccines:

  • T-VEC (talimogene laherparepvec; Amgen [BioVex])
  • PROSTVAC (rilimogene galvacirepvec-rilimogene glafolivec; Bavarian Nordic, Bristol-Myers Squibb)
CD19-targeted CAR-T Treatments:
  • Tisagenlecleucel-T (anti-CD19-CAR transduced T cells; Novartis)
  • KTE C19 (anti-CD19 chimeric antigen receptor transduced T cells; Kite)
  • JCAR 014 (anti-CD19/4-1BB/zeta modified CAR CD8+ central memory and CD4+ T lymphocyte therapy; Juno Therapeutics)
  • JCAR 017 (anti-CD19-EGFRt-4-1BB-zeta modified CAR CD8+ and CD4+ T lymphocyte therapy; Juno Therapeutics)
  • JTCR 016 (WT1-sensitised allogeneic T-lymphocytes; Juno Therapeutics)

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