Collaborative Cancer Care: Express Scripts and the National Comprehensive Cancer Network

Specialty Pharmacy Times spoke to Milayna Subar, MD, vice president and national practice leader in oncology for the Oncology Therapeutic Resource Center (TRC) at Express Scripts, to learn more about how access to clinical practice guidelines in oncology can help shape the complex landscape of cancer treatment.

Attendees at this year’s American Society of Clinical Oncology meeting expressed an overwhelming need for effective and coordinated cancer care. In response to this need, Express Scripts entered into a new license agreement with the National Comprehensive Cancer Network (NCCN) for use of the NCCN Drugs & Biologics Compendium. This resource—designed to control the cost of specialty medications and improve care for patients—helps guide the appropriate use of specialty medications and biologics.

To learn more about this resource and how its use will help cancer patients, Specialty Pharmacy Times interviewed Milayna Subar, MD, vice president and national practice leader in oncology for the Oncology Therapeutic Resource Center (TRC) at Express Scripts.

Dr. Subar leads oncology specialty pharmacists and stresses the importance of integrating evidence-based treatment approaches for cancer into the practice of pharmacy. Dr. Subar’s previous experience includes senior director and team leader in the Oncology Global Medical organization at Pfizer, Inc; senior director of clinical development, internal medicine and oncology for the Daiichi Pharmaceutical Corp; and associate director of medicine and medical director at the North Central Bronx Hospital affiliate of Montefiore Medical Center.

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Q. What will Express Scripts’ collaboration with the NCCN mean for cancer patients, and how will it affect their treatment paths?

A: The collaboration with NCCN will support Express Scripts’ efforts to improve patient care while expanding physicians’ access to clinical resources. By integrating the NCCN Compendium into our ExpressPAth tool, we will enable physicians to focus less on administrative tasks and more on caring for patients. We expect that this collaboration will increase oncologists’ compliance with treatment regimens that are recognized by national experts from the 21 NCCN member institutions. Since the information will be combined with our system’s ability to provide real-time prior authorizations for treatment, patients will receive the care they need faster.

Q: Spending on oncology drugs is expected rise more than 20% annually for the next few years, reaching $173 billion by 2020, according to Express Scripts. How do you think consumer out-of-pocket costs for these drugs will be affected?

A: Since oral oncology medications are often identified as "specialty medications," they are often placed on a higher tier within a drug formulary. For these medications, plan sponsors are increasingly choosing a pharmacy benefit plan that may require a percentage coinsurance billed to a patient rather than a fixed copayment.

Cost-sharing in the form of coinsurance is also often seen in medical benefit plans, and as we cited in our 2011 Drug Trend Report, approximately 78% of oncology drug costs are billed through the medical benefit. As oncology drug costs continue to increase, we expect that member cost shares will also increase, based on the growing preference of plan sponsors to require their members to bear some of the cost.

At Express Scripts, we focus on minimizing waste, so that patients only receive the quantity of medication they are going to use without spending on excess that will remain in the medicine cabinet. Additionally, we implement clinical adherence programs so that patients get the most benefit out of the therapy they have been prescribed.

Q: How do you think health plans will adjust to the increasing number of oral oncolytics in the pipeline?

A: Nearly half of all drugs in the development pipeline are cancer drugs, many of which will be administered orally. While the development of these drugs brings the promise of new treatment and improved care for patients, they also represent a challenge for plan sponsors. Many of these oral oncolytics will be costly, and health plans will need to manage them appropriately. Health plans are increasingly using utilization management strategies and coverage rules, such as prior authorization, to support coverage for the new medications in the indications for which they are approved, or in certain select cases, where there is strong evidence that supports their use outside an indication. Oncologists will need access to the most up-to-date, evidence-based criteria as the options for cancer care continues to grow, and that will make our collaboration with NCCN even more important.

Q: Should the pricing of oral anti-cancer medications be similar to the pricing for intravenous cancer medications?

A: Oral oncology medicines can be just as effective as intravenous medicines, and both options pose comparable complexity for prescribing and patient management.

The cost of chemotherapy agents can vary significantly regardless of how the drug is administered. Newer targeted agents — whether oral or infused— are often more costly then some of the older chemotherapy agents, which is often a result of the cost to bring a drug to the market. Additionally, some of these agents may have pharmacogenomic or companion testing associated with them to determine efficacy for a specific patient.

Regardless of cost, maintaining high levels of adherence to oral oncology medicines is a key consideration for maximizing efficacy and minimizing medical spend. To ensure optimal clinical outcomes, Express Scripts extensively educates patients on how to recognize and manage side effects.

Q: Do you think eventually all cancer treatment will be covered under the pharmacy benefit?

A: Cancer treatments that are infused or injected are frequently administered in a physician’s office and billed through a medical benefit under what is commonly referred to as “buy-and-bill.”

The number of oral oncology drugs in the pipeline and the decreasing use of buy-and-bill practices by physicians will drive more drugs to be covered under the pharmacy benefit in the future. However, due to the clinical care required at the time of administration, some oncology drugs will continue to be administered in a medical setting and billed under the medical benefit.

Regardless of the benefit under which a specialty drug is billed, Express Scripts has the ability and the experience to manage the costs and help plan sponsors reduce waste. Since we manage both pharmacy-billed and medically billed drugs, we are also able to manage patient care more comprehensively.

Q: Is personalized medicine a trend in oncology that you think will last? What will personalized medicine mean for specialty drug utilization?

A: Oncology is at the forefront of personalized medicine. Researchers are continually discovering specific genetic mutations that occur in cancers that provide the engine for the cancer to grow. We can often test for the presence or absence of such a mutation and on that basis determine whether a treatment is more or less likely to work. The trend of personalized medicine in oncology is expected to grow, and many investigational therapies currently being studied to treat cancer rely on a personalized medicine approach requiring special biomarker testing before prescribing.

Express Scripts only recommends pharmacogenomic testing when clinical evidence suggests that the results of the test could guide therapy. To improve patient care, our team of physicians, pharmacists, and researchers have already integrated proven personalized medicine interventions into our clinical programs. We continue to evaluate each pharmacogenomic test as they become available and advise our plan sponsors to adopt those tests that demonstrate clear value.

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For more on Express Scripts’ collaboration with the NCCN, visit Express Scripts’ blog.