Managing BTKis for Coverage

Roy Beveridge, MD, discusses how payers and health systems are managing Bruton tyrosine kinase inhibitors and how they are chosen for formulary and pathway coverage.

Ryan Haumschild, PharmD, MS, MBA:Let’s shift a bit to our payer colleagues to get some feedback on our BTKis [Bruton tyrosine kinase inhibitors]. How are payers or health systems managing the BTK inhibitors? Dr Beveridge, I’ll turn to you on that one. How are many BTK inhibitors chosen for formulary or pathway coverage? And what kind of evidence or data do you usually try to look at? Is it outcomes data that’s meaningful? What are some of those end points that are most significant to you?

Roy Beveridge, MD: First of all, let’s remind people; don’t think of insurance as 1 monolithic block, because if you do, you’re going to hurt yourself. You do have to think of the 50 state Medicaid entities as different. Each one of them is different, what they’re going to cover is different, and their budgets are different. Then on your commercial side, you have to break the commercial world up into companies that are fully insured, so they’re taking the risk themselves, they tend to be the most generous. Then you’ve got smaller companies who give risk to a payer, and they’re going to be a little tighter because they are ultimately responsible for the number of dollars being spent within the plan. And then, you have Medicare. And by the way, 50% of Medicare is now Medicare Advantage. You have to understand there are different patterns there also.

But if you take a step back, for plans that have less money, they’re going to want to choose 1 of the 2 BTKis. If we can get to the world where there’s the first line, and then there’s second line, and we can prove with Pirto [pirtobrutinib] that there’s salvage and that it’s reasonable for people to be on this after a first-line therapy, that’d be great. People will cover that. What payers don’t want to pay for are more expensive drugs when there’s no increased efficacy. That’s we have to keep reminding ourselves. We, as a society, think this is an expensive drug, the payer’s not willing to pay for it. Remember that by shifting money into this treatment for CLL [chronic lymphocytic leukemia] for a very expensive drug, it’s worthwhile shifting money if there’s improvement in whatever we want to talk about improving. But we still have to take care of patients with diabetes and all these other things, for which there are increasing costs also. It’s a balloon that is not infinitely distensible. I think that’s the issue we have to remember.

Ryan Haumschild, PharmD, MS, MBA: What are some of those key factors that you take into consideration? Is it quality of life? Is it the financial considerations, or the outcomes? How do you balance this?

Roy Beveridge, MD: Payers don’t have CLL experts in each state thinking about how to treat patients in California with CLL. And they don’t have sarcoma experts, they have oncology people, but they don’t have the deep expertise that we see here at ASH [American Society of Hematology annual meeting] or elsewhere. They inevitably rely on NCCN [National Comprehensive Cancer Network] guidelines. And when there’s not total clarity with NCCN guidelines, they’re going to look at other guidelines or they’re going to look at key opinion leaders [KOLs]. If KOLs say, “Look, line therapy 1, line therapy 2, this is what we think should be done,” payers would usually follow that. But if there’s not a consensus, then they’re going to say, “Well, I’ve got a free choice because the experts can’t agree.”

Ryan Haumschild, PharmD, MS, MBA: One of the things I think is important when we have new therapies, if we can reduce that total cost of care, create agents that reduce the adverse effects so that patients are more compliant, and reduce other external health care resource utilization due to adverse effects, and ultimately have better outcomes, then it’s great to have additional agents in the space. We get that compendia support through NCCN and others. I think those are excellent options to have and that our payer colleagues will support that as well.

Roy Beveridge, MD: Just a number for people to hold their hat on, let’s take any major national payer. Their pharmacy budget is whatever it is, a billion dollars. Half of that now is driven by specialty cost, and that half is driven by 1.5% of their membership. That means that 98.5% of folks aren’t using any of these expensive drugs; 1% is using all of these expensive drugs. And they’re becoming very careful as to what 1% is going to start using these expensive drugs. That’s why this consensus becomes so important.

Transcript edited for clarity.

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