An expert discusses how payers face multiple access challenges including high treatment costs exceeding $100,000 per patient, coverage restrictions through prior authorization and operational barriers requiring specialized administration facilities, and proposes solutions like value-based contracting and enhanced patient selection tools.
An expert discusses how health plans prioritize the lowest net cost with positive outcomes when comparing administration differences, ultimately focusing on member experience when deciding between quarterly intravesical treatments and more frequent systemic infusions.
An expert discusses how health plans currently don’t utilize real-world evidence for decision-making due to lack of common standards and limited data at drug launch, but explains that AMCP is developing an RWE framework with different protocols for various drug life cycle phases.
An expert discusses how health plans evaluate high-cost NMIBC therapies by examining total cost of care, weighing risk versus reward for treatments like gene therapy that can cost over a million dollars, and using frameworks from NCCN guidelines and ICER to perform comparative effectiveness analyses.
An expert discusses how health plans must defend all formulary decisions with clinical evidence and use NCCN/AUA guidelines to create treatment pathways rather than traditional tier placements, with BCG-unresponsive cases following a step-therapy approach from gemcitabine/docetaxel to nadofaragene based on cost and toxicity profiles.
An expert discusses how health plans establish coverage policies by referring to clinical trials, NCCN guidelines and disease association recommendations, using trial qualifying criteria to draft prior authorization requirements that are then reviewed by specialists before committee presentation.
