Considerations Related to the Coverage of Immuno-Oncology Therapies

During this one-on-one interview, a part of the Oncology Stakeholders Summit, Spring 2015 series, Michael Kolodziej, MD, discusses payer considerations regarding coverage for new cancer treatments such as immuno-oncology therapies.

Dr Kolodziej, national medical director of oncology strategy for Aetna, remarks that the PD-1 agents, including the FDA-approved checkpoint inhibitors pembrolizumab and nivolumab, have generated a great deal of excitement in the oncology community. These drugs are related in terms of their mechanisms of action, and Dr Kolodziej describes the potential opportunity for oral oncolytics to be managed by class effect. Rather than payers deciding whether or not certain drugs will be treated as a class, it is likely that companies or physician groups that develop treatment pathways will recommend a limited number of agents, taking into account safety and efficacy data and drug cost.

Payers’ coverage decisions are currently reflective of FDA approvals and recommendations from the National Comprehensive Cancer Network (NCCN), notes Dr Kolodziej. “Payers tend to respect, at least initially, the FDA label and subsequently expert opinion like that offered by the NCCN. I would say that if a payer made a decision that was in conflict with NCCN, they’d be in a very difficult place to defend that decision.”