Beneficiaries may need to pay coinsurance for orally delivered oncology drugs, says new report

HealthLeaders-InterStudy and Fingertip Formulary find that over the next five years, a greater percentage of health plans will transition orally delivered oncology drugs from a copayment structure to a reimbursement model that incorporates a coinsurance payment, thereby shifting more costs onto patients. Copayments represent a set dollar amount associated with a pharmacy benefit while coinsurance represents a percentage of cost that must be paid by the beneficiary.

According to the new Formulary Forum report entitled Formulary Advantages in Orally Delivered Oncology Agents: The Impact of Cost Controls and Emerging Agents on Key Brands, surveyed pharmacy directors from national and single-state health plans indicate that by 2014 more than half of their beneficiaries will be required to pay coinsurance for orally delivered oncology drugs. However, pharmacy directors from regional health plans indicate they will shift a smaller percentage of patients to the coinsurance model, but will keep the greatest percentage of beneficiaries on copayment-only plans.

"Currently, the vast majority of health plans we surveyed charge a copayment for orally delivered oncology agents," said Analyst Jennifer Moniz Carpenter, M.B.A. "The transition from a copayment to coinsurance structure suggests that health plans will attempt to control costs by shifting a greater percentage of the expense of these agents back onto the patient."

The report also finds that over the next five years, surveyed pharmacy directors at national and regional health plans will lower their co-insurance percentages on orally delivered agents to treat hematological cancers. Orally delivered agents for hematogical cancers include Novartis' Gleevec, Celgene's Revlimid and Bristol-Myers Squibb's Sprycel.

The new Formulary Forum report is based on a survey of 50 U.S. pharmacy directors who control formularies at national, regional and state-level managed care organizations, as well as historical formulary data from Fingertip Formulary.