IQVIA: Payers Increase Exclusions for Oncology Drugs

Previously rare in oncology, formulary exclusions are becoming a way for national insurers and PBMs to have some control over oncology drug expenditures, finds a new report from IQVIA. From 2021 to 2022, there was a 40% growth in the use of exclusions where a generic or biosimilar is preferred. In 2022, the seven top national payers and PBMs have a combined 94 oncology exclusions, 34 of which have only brands for preferred alternatives.

Jing Yang

“With the impact of COVID-19 (and now long COVID), payers are seeking innovative ways to help with cash flow and reduce financial risks,” Jing Yang, principal, IQVIA US Market Access Strategy Consulting told Formulary Watch. “As more treatment options become available and as the treatment paradigm for certain tumor types shifts from ‘acute’ to ‘chronic disease management, payers will continue to look for ways to minimize longer term budget impact, with the utilization of formulary exclusion being one of them.”

With new product approvals and existing product label extensions, payers, especially national payers, continue to expand their use of formulary exclusions with no sign of slowing down the oncology formulary control, Yang said.

The overall cost burden of oncology – particularly as many patients live with cancer and manage it like a chronic condition – is only expected to grow. “Americans are getting older, and that brings a growing demand for healthcare, including cancer medicines,” she said. “Payers will look to mitigate costs and achieve better cost-effectiveness where they can, and managed formularies may help them extract higher rebates as well as manage utilization.”

IQVIA’s analysis follows research by others that shows formulary exclusions across therapeutic areas are increasing. Xcenda earlier this year released an analysis of the three largest PBMs — CVS Caremark, Express Scripts, and OptumRx. This analysis finds the largest PBMs excluding medicines in classes where generics are not available or for serious conditions, such as oncology and autoimmune disorders.

Related:PBM Exclusions Increasing, Finds New Analysis

IQVIA’s analysis find that oncology formulary exclusions continue to be most common in tumor types where competition is greatest, such as breast cancer, chronic lymphocytic leukemia, and non-Hodgkin lymphoma. Additionally, several branded medicines that faced biosimilars in 2019 are only just now seeing their first formulary exclusions at the national level. These include three products from Genentech: Avastin (bevacizumab), Rituxan (rituximab), and Herceptin (trastuzumab).

But researchers said that exclusions don’t necessarily mean patients have to use less appropriate treatment. They found that 96% of exclusion were in favor of preferred alternatives that had the same National Comprehensive Cancer Network (NCCN) clinical rating as the excluded brand. “For patients, the exclusions will unlikely significantly disrupt the overall treatment,” Yang said. “Additionally, the system may benefit from reduced cost alternatives. However, formulary exclusions may make patients feel that fewer options are available, even though there are other options that can achieve similar outcomes.”