Contact: Melinda Haren
The Zitter Group
33 Bleeker Street, Suite 200
Millburn, NJ 07041-1460
Phone: (973) 376-1300 x160
[email protected]
PRESS RELEASE
Expansion of Prior Authorization Policies for Oncology Agents
Facing new agents and rising costs, payers continue to tighten their management of oncology.
Millburn, NJ – April 27, 2012: 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 continues 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
PAGE 1
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
ABOUT THE ZITTER GROUP
The Zitter Group is a business intelligence firm that assists life science companies with issues related to product
access, reimbursement, and managed markets. Founded in 1989, The Zitter Group provides data-driven
business insights derived from the nation’s largest payer research panel. The company produces the largest and
PAGE 2
most detailed database on prior authorization policies, several of the largest syndicated studies on payer
management of specialty and oncology drugs, and the only service tracking messages account managers
provide to payers. For additional information on The Zitter Group, please visit http://www.zitter.com.
ABOUT THE PRIOR AUTHORIZATION TRACKING TOOL
The Prior Authorization Tracking Tool is the largest database of detailed health plan prior authorization
policies and metrics from more than 450 commercial and government payers. This comprehensive,
interactive database employs a proprietary system to quantify the restrictiveness of each plan’s PA to
help pharmaceutical managed care marketing and sales professionals understand the scope of PAinfluence access across accounts, the impact of restrictiveness on geographic populations and market
share, and the competitive climate of a given drug category.
PARTICPATE IN FUTURE RESEARCH STUDIES CONDUCTED BY THE ZITTER GROUP
Are you an MCO professional interested in participating in The Zitter Group’s research studies? Please
contact Linda Dordevic at [email protected] for more information.
###
PAGE 3