Oncology Utilization Management Summaries Series

Oncology Utilization Management: Prior Authorizations in Oncology

Prior authorizations (PAs) are a common utilization management tool used by managed care plans to control the use of prescription drugs. PAs require prescribers to get preapproval before a plan will cover, or pay for, a prescribed drug.

Oncology Utilization Management: Managing to FDA Labeling

Managing to FDA labeling is a utilization management tool used by health plans and pharmacy benefit managers (PBMs) to control the use of prescription drugs and potentially reduce costs.

Oncology Utilization Management: Increasing Patient Cost-Sharing and Using Tiered Formularies

To manage utilization of cancer drugs, more payers are increasing patient cost-sharing and using tiered formularies. By shifting more costs to patients, payers aim to reduce their own costs while discouraging use of more expensive therapies.

Oncology Utilization Management: Using Case Management

Case management (sometimes called care management) is a strategy to reduce costs during cancer treatment by preventing inappropriate utilization and helping patients manage their disease.

Oncology Utilization Management: Setting Quantity Limits and Using Split-fill Programs

Quantity limits and split-fill programs are utilization management tools used by payers to control the use of prescription drugs. Quantity limits, also known as supply limits, restrict the amount of a drug that a payer will cover during a specific time period.  Split-fill (also known as partial-fill) programs dispense medications in half-quantities (such as a 15-day supply instead of a 30-day supply) and often target drugs with high discontinuation rates, including oral oncology products.

Oncology Utilization Management: Implementing Step Edits (“Fail First” Policies)

Step edits, also known as step therapy or “fail first” policies, are the most common method used by payers to manage utilization of specialty drugs, according to a study by Health Affairs. These policies require that a patient try a payer’s preferred generic or brand as the initial “step” before another brand will be covered — even if the physician recommends a different brand in the same class or category as the payer’s preferred drug.

Oncology Utilization Management: Excluding Drugs from the Formulary

To manage utilization of cancer drugs, more pharmacy benefit managers (PBMs) and health plans are excluding drugs from their formularies. With formulary exclusions, these payers aim to limit patient access to more expensive drugs and reduce drug spending.

Oncology Utilization Management: Optimizing the Site of Care

Patients can receive infusions of anticancer drugs in multiple settings, including hospital outpatient clinics, physician offices, standalone infusion clinics, and at home (via home infusion providers). Not all of these options cost commercial health plans the same: Hospitals tend to be the most expensive sites, compared with other settings. (That said, Medicare payments for outpatient chemotherapy do not vary much by site of care.) Site of care optimization is an increasingly popular strategy that many commercial health plans are using to contain costs. Specifically, they are implementing policies to transition more patients from receiving infusions in hospital settings to less costly settings that are still clinically appropriate.

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