艾昆纬-癌症患者旅程中的获取挑战-口腔肿瘤学的障碍如何影响患者的开始和坚持（英）-2024-WN8

WhitePaper

AccessChallengesintheCancerPatientJourney

Howbarrierstooraloncologyaffectpatientinitiationandpersistency

JEFFTHIESENManagingPrincipal,U.S.MarketAccessStrategyConsulting

RUTHYGLASSManagerofThoughtLeadership,U.S.MarketAccessStrategyConsulting

CLAUDIALAMPRECHTAssociateConsultant,U.S.MarketAccessStrategyConsulting

August2024

Tableofcontents

Introduction1

Overview2

Expandingformularycontrols3

Dispensingsiteeffects9

Financialsupportinoncology13

Thepast,present,andfutureofcontrolinoncology18

Notesonsources19

References20

Abouttheauthors21

Introduction

Oncologyisoneofthefastest-growingmarketsintheU.S.,withtotal

medicinespendingincreasing$10billionto$91billionfrom2022to2023.1As

developmentsincancertreatmentadvance,wearenowatapointwithmany

tumortypesatwhichmultipleoptionsforeffectivetherapyhaveemerged,

andextendedsurvivalisleadingtoincreasedutilizationofthosetherapies.

Marketcompetitionandhighervolumepromptpayerstoincreasecontroland

raisehurdlestoaccess.Theabilityforpatientstoinitiateandmaintaintherapy

iscrucialforsuccessfultreatmentanddiseasemanagement,butwehave

identifiedbarriersthatundercutfavorableoutcomes.

Everyday,millionsofcancerpatientsrelyontheirAnotherexampleistheaccessibilityofdispensingsites.

medicationstoimprovetheirwell-beingandsurvival.Optionalityandpatientchoiceshavebecomemore

Obtainingthattherapyisanecessaryfirststep,yetlimitedwiththeuseofpayernetworksthatoftenrequire

accesscontrolsinoncologyareexpanding,constrictingorincentivizepatientstofillprescriptionsviaspecific

patients’abilitiestostartandstayontherapy.pharmacies.Thesenetworksareoftenintegratedwiththe

Since2021,IQVIAhasbeentrackingtheuseofformulary

payerandimpactspecialtymedicinesmorethanothers.

exclusionsinoncologymedicinesaffectingbothThestartof2024sawthefirstwaveofchangestothe

provider-andself-administeredtreatments.2,3TheseMedicarePartDBenefitdesignstipulatedbytheInflation

controlsareontheriseandaregrowingmoreimpactfulReductionAct(IRA).Thisincludedtheeliminationofthe

astheuseoforaloncologyproductscontinuestogrow,5%patientcoinsuranceintheCatastrophicphase,which

andaspayersshiftinfusedoncologyproductsawayfromcouldimproveaffordabilityformanypatients.However,

thebuy-and-billmodelintointegratedbenefitmodelsitisexpectedshiftingcostsandliabilitiesfromtheIRA

andfavorspecialtypharmacies(“white-bagging”)viathewillalsoleadtogreaterpayerrestrictionsand”skinny”

pharmacybenefit.4formularies.Eveninprotectedclassessuchasoncology,

Withinthepharmacybenefit,patientaccesscan

beimpactedbyseveralfactorsbeyondformulary

whererestrictionsarealreadyincreasing,theriskofeven

greatercontrolisathreattomany.

exclusions.Amorewell-knownbarriertoaccessisJeffThiesen

affordability.AsdrugpricesbecomeafocusofpublicandManagingPrincipal

politicalattention,therolethatfinancialsupportplaysU.S.MarketAccessStrategyConsulting

intherapyacquisitionbecomesincreasinglypertinentin

thediscussionofoncologyaccess.

|1

Overview

Expandingformularycontrols

Financialsupportinoncology

Cancerpatientscanfacecostsashighas$500ormore

perprescription.Tofacilitateaffordability,copaysupport

Payerformulariesmayoutrightexcludetherapies

programstakeanumberofformsbutaremostoften

fromcoverageorfirstrequirepatientstofulfillprior

manufacturer-sponsoredcopaycardsusedamong

authorization,steptherapy,andspecificpharmacy

privatelyinsuredpatientsandcharitablegiftsfrom

fulfillmentrequirements.Theseutilizationmanagement

foundationsusedbyMedicarepatients.Theseprograms

techniques,thoughlargelylimitedtothepharmacy

playacrucialroleintreatmentcompliancebutarea

benefit,haveincreasedacrossbothself-andphysician-

limitedresourcethatcouldfacemoredisruptionasthe

administeredoncologymedicines.

IRAimpactsfunding.

•Therewere134formularyexclusionsof186products

•In2023,76%ofMedicarepatientswithoutsupport

acrossfivepayersin2024,upfrom37exclusions

facedprescriptioncostsabove$500versus13%of

in2020.

thosewithsupport.

•Priorauthorizationandsteptherapyrequirements

•Medicarepatientswhoutilizedsupportwere~20%

werethemostcommonrejectiontypeacross

payerchannels.

morelikelytocontinuetherapythanthosewithout.

•Whenpatientsworkedthroughrestrictions,ittook

themuptotwiceaslongtoinitiatetherapyasthose

withoutrestrictions.

Dispensingsiteeffects

Generally,patientshaveoptionsforwheretheywould

liketofilltheirprescriptions:medicallyintegrated,

specialty/mail,andretailpharmacies.Eachtypeoffers

differentlevelsofaccessibilityandconveniencefor

patients,butbecausepayerrestrictionsofteninclude

limitedpharmacynetworks,patientsmightencounter

rejectionsrelatedtotheirdispensingsite.Patients

fillingprescriptionsthroughmedicallyintegrated

andspecialty/mailpharmaciesaremoresuccessfulat

overcomingaccesschallengessuchascostsandpayer

restrictionsrelativetoretailpharmacies.

•Medicarepatientsthatovercomerejectionsdosomost

quicklyatmedicallyintegratedsites.

•Specialty/mailandmedicallyintegratedpharmacies

hadlowerratesofabandonmentrelativeto

retailpharmacies.

2|AccessChallengesintheCancerPatientJourney

Expandingformularycontrols

Everyaccessbarrierisathreattotheinitiationofa

therapyprescribedbyapatient’sphysician.Forcancer

Astheoraloncologymarketgrowsandwhite-bagging

patients,gettingonthesetreatmentsinatimelymanner

formedicalproductsbecomesincreasinglyprevalent,

canbecrucialfortheirwell-beingandsurvival.

payersutilizeanumberofcontrolstomanageaccess.

KEYTAKEAWAYS:

Formularyexclusionshaveincreased,particularlyfor

productswithgenericalternatives.Thoughmarket

expansionintheformofnewlaunchescurrently

outpacestheincreasingformularyexclusions,such

•FollowingaPayerrejection,ouranalysisindicates

that43%ofCommercialand53%ofMedicarepatients

neverinitiatetherapy.

exclusionscanpreventtimelyaccesstothese

•Only10%ofCommercialand23%ofMedicare

life-savingmedicines.

patientsreceivedpayerapprovalonthefirstdaytheir

“Coverage”isabluntmeasureofproductaccess.For

prescriptionwassubmitted.

medicinesonformulary,payerscanutilizeotherformsof

•Since2020,thenumberofoncologyproduct

controltomanageutilization,alsodelayingtreatmentor

formularyexclusionsamongtopnationalpayersgrew

haltingtherapyaltogether.Asmoreverticalintegration

from37to134,mainlyforproductswithgenericor

betweenpayersandspecialty/mailpharmaciesdevelop,

biosimilaralternatives.

payersincreasinglymandatewhereandhowpatients

canreceivetheirmedications.

•Formularyexclusionswereapplicableacrossarangeof

tumortypesandmodesofadministration.

Theoverwhelmingmajorityofpatientsfacebarriersto

access,andonlyroughlyhalfofthosepatientseverfill

thetreatmenttheywereprescribedwithinoneyear.For

20%ofthosethatdo,ittakesatleastfourweeksfortheir

prescriptiontobeapproved.

•Thoughoralproductshavethegreatestnumber

offormularyexclusions,productsadministered

intravenously,subcutaneously,andintramuscularly

areimpactedaswell.

•Amongthosethatwereapproved,20%ofpatientshad

towaitoverfourweeksforinitialtherapy.

|3

Formularyexclusionsforoncologymedicationscontinuetoexpandincompetitivebrand

andlow-costalternativescenarios

Exhibit1:Numberofnationalformularyexclusionsbyyear,topnationalpayers,oncologyproducts,

Commercial

150

130

110

90

70

60

94

34

116

40

134

42

50

30

10

24

37

22

16

1015

34

33

60

76

92

-10

20172018201920202021202220232024

BlockwithgenericorbiosimilaralternativesBlockwithonlybrand-preferredalternatives

Source:PublishednationalCommercialformularies;IQVIAU.S.MarketAccessStrategyConsultinganalysis

•Asmoreoncologyproductsaredevelopedand•Formularyexclusionsarejustonestrategypayerscan

broughttomarket,competitionforfavorableusetocontrolaccess;typesofrestrictionscouldbe

formularyplacementincreasesbetweenproducts.priorauthorization,steptherapy,orotherformulary

•AcrosstopnationalCommercialformularies,there

requirements.

were134formularydecisionstoexcludeoncology•Inadditiontorejections,payersaffectaccessthrough

productsin2024.patientcost-sharing(deductibles,copaytiers,

•42oftheexclusionsin2024occurredwherethe

preferredalternativeswerebrandsonly.

coinsurance).

•Theremaining92excludedproductswereinfavorof

lowerlistpricegenericorbiosimilaralternatives.

Notes:Exclusionsarecountedaspayer-productcombinations.

Aproductisconsideredexcludediftheformularyexplicitlystatesso;productsleftoffformularyarenotcounted

4|AccessChallengesintheCancerPatientJourney

Formularyexclusionsarenotlimitedtocertainmodesofadministrationortumortypes

Exhibit2:Nationalformularyexclusions,topnationalpayers,oncologyproducts,Commercial

ModeofadministrationTumortype

Oral

IV

SubQ

IM

7

10

13

5

6

5

34

37

48

49

57

72

Breast

NSCLC

Prostate

CLL

NHL

9

11

13

16

13

15

14

13

15

22

22

20

2528

33

020406080

Numberofexclusions

010203040

Numberofexclusions

202220232024202220232024

Source:PublishednationalCommercialformularies;IQVIAU.S.MarketAccessStrategyConsultinganalysis

•Formularyexclusionsarenotlimitedtooralproducts•Exclusionprevalencespansacrossanumberof

alone.Therapiesadministeredintravenously,tumortypes.

subcutaneously,andintramuscularlyareimpacted,

aswell.

•Thegreatestnumberofexclusionshavebeenplaced

onbreastcancerproducts,withatotalof33in2024.

•Statedexclusionsoforalcancermedicinesgrewover

time,reaching72exclusionsin2024.

•Non-smallcelllungcancerproductshadthegreatest

increaseinexclusionsamongtumortypesin2024,

•ThenumberofexclusionsforIVproductsgrewby48%doublingfromtheyearbefore.

from2023to2024,reaching49exclusions.

•Increasedformularyexclusionsinbreastandlung

•Theexclusionofphysician-administeredproductscancerarepartlytheresultofanincreaseinthe

onformulariessuggeststhatpayersarecontrollingnumberofapprovedtreatmentalternativesand

productsthatareregularlywhite-bagged.increasedmarketcompetition.5

Notes:Exclusionsarecountedaspayer-productcombinations.

Aproductisconsideredexcludediftheformularyexplicitlystatesso;productsleftoffformularyarenotcounted.Tumortypeschosenbasedonthegreatestnumberofexclusionsin2024.

Someproductshavemultiplemodesofadministrationsand/orareindicatedformultipletumortypes.

IV—Intravenous;SubQ=Subcutaneous;IM=Intramuscular;NSCLC=Non-smallcelllungcancer;CLL=Chroniclymphocyticleukemia;

NHL=non-Hodgkin’slymphoma

|5

After4+years,coverageisexpandingforbiosimilarswithsharereachingabove70%

acrosstherapies

Exhibit3:Formularystatusandmarketshareuptakeofbiosimilars,oncologyproducts,allpayerchannels

70

100%

60

50

40

30

20

10

8

20

29

14

1618

10

25

25

80%

60%

40%

20%

62%

86%

78%

72%

63%

63%

0

0%

20222023202403691215182124273033363942454851

PreferredExcludedNotlisted

Monthssincebiosimilarintroduction

bevacizumab(7/2019)trastuzumab(7/2019)

rituximab(11/2019)Retail/Mail%

Source:PublishednationalCommercialformularies;IQVIANationalSalesPerspective;U.S.MarketAccessStrategyConsultinganalysis

•Therearecurrentlythreecancer-treatingtherapies•98.5%ofmedicaloncologyproductsflowedthrough

thathavebiosimilarsonthemarket:bevacizumab,thebuy-and-billsystem,whilesomepatientsreceived

rituximab,andtrastuzumab.theirmedicationviawhite-bagging(dottedline)inthe

•In2022,therewereatotalof10launchedoncology

retail/mailacquisitionchannel.

biosimilardrugs;11morelaunchedin2023;12more•Inbuy-and-bill,bevacizumabandrituximabbiosimilars

in2024.reached50%ofshare15monthspost-launch;

•Acrossallfivenational,Commercialformularies,at

leastonebiosimilarwaspreferredoveraninnovator.

trastuzumabbiosimilarsdidnotreach50%until21

monthsafterintroduction.

•Evenwhenproductsareincludedonformulary,

patientsmayfaceotherutilizationmanagement

toolssuchaspriorauthorizationsorsteptherapy

requirementswhichcanimpedepatientaccess.

•Unlikewhite-baggedclaims,buy-and-billprescriptions

areaffectedbyphysician/practiceeconomicsthat

favordiscounts.

•In2024,biosimilarswerecovered42%ofthetimeon

nationalformularies,anincreasefrom32%inboth

2022and2023.

Notes:Exclusionsarecountedaspayer-productcombinations.Currently,biosimilarsareonlyavailableformedicaloncologyproducts.

Whilebiosimilarsexistforfilgrastim,pegfilgrastim,andepoetin,thesetherapiesareconsideredsupportivecareasopposedtooncologytreatments.Volume

determinedbyeaches,definedasthenumberofsingleitems(vials,syringes,bottles,etc.)containedinaunitorshippingpackage.

6|AccessChallengesintheCancerPatientJourney

Over75%ofcancerpatientsmustovercomeaninitialrejectionfortheirmedication,

regardlessofpayerchannel

Exhibit4:Initialandfinal30-dayclaimstatusbypayerchannel,brandedoraloncologytherapy,2020-2023

CommercialStandardMedicare

100%

80%

60%

33%

14%

41%

50%

14%

40%

40%

10%

16%

58%

40%

20%

0%

14%

17%10%

11%

IntialFinalInitialFinal

RJ-NotcoveredRJ-PA/StepRJ-AdminAbandonedFilled

Source:IQVIALAADPharmacyClaimsdata;U.S.MarketAccessStrategyConsultinganalysis

•Patientscanfaceoneofthreetypesofrejections:a•Theincreasingintegrationofpayersandpharmacies

rejectionthattheproductisnotcoveredonformulary;alendsitselftonarrowernetworksforpatients.

rejectionspecifyingthatpriorauthorization(PA)orstep

therapyisneeded;oranadministrativerejection(e.g.a

patientisfillingaproducttoosoonorquantitylimit).

•Despite81%approval,onlyhalfofnewMedicare

patientsultimatelyfilledtheiroraloncology

medicationwithin30daysofaninitialattempt.

•Only10%ofCommercialand23%ofMedicarepatients

areapprovedontheirfirstattempttofillabranded

oraloncologytherapy.

•ThehighabandonmentinMedicarewasmostlikely

duetotheespeciallyhighcostspatientsface.

•Themostcommonrejectiontypeforallpatientswas

aPAorsteprequirement,necessitatingadditional

providerinputforapprovalandburdeningproviders

•HavingalreadyeliminatedCatastrophiccoinsurance

in2024,theIRAwillalsolowertheout-of-pocketcap

in2025.

withpaperwork/tests.

•However,industrystakeholdersexpectcontrolsto

•ForCommercialpatients,halfofalladministrative

rejectionswereduetorequirementsthatpatientsfill

throughspecified,specialtypharmacies.

growevenmorestrictinMedicarePartsDandBasIRA

increasespayerliabilities.

Notes:Brandsincludetreatmentsagainstbreast,lymphoma,leukemia,prostate,andnon-smallcelllungcancer;

AnInitialclaimstatusisdefinedasapatient’sfirstattempttofillaprescription;finalstatusistheultimateoutcomeoftheclaim30daysaftertheinitialattempt.

|7

PayerrejectionsdelayCommercialandMedicarepatientsfrominitiatingtherapybyan

averageofthreeweeks

Exhibit5:Timetotreatmentbyinitialclaimstatus,brandedoraloncologytherapy,2020-2023

CommercialStandardMedicare

Initially

approved

patients

87%8%

AvgdaysAvgdays

7

82%9%10

Initially

rejected

patients

54%19%21%2064%13%19%18

0%50%100%0%50%100%

%Paidclaims%Paidclaims

1Week2Weeks3Weeks4+Weeks

Source:IQVIALAADPharmacyClaimsdata;U.S.MarketAccessStrategyConsultinganalysis

•Payerrejectionscanoftenplacemultiple,time-•Around20%ofinitially-rejectedpatientshadatleasta

consumingrequirementsonpatientsandproviders4-weekdelayininitiatingtherapy.

beforeapproval,suchasauthorizationforms,

additionaltests,changesindistributionsite,etc.

•IttooknearlythreetimesaslongforCommercial

patientswhowereinitiallyrejectedtoinitiatetherapy

•Administrativeorphysicaldelaysmaymakeitsothat(20days)versusthosewhowereinitiallyapproved(7

patientsdonotalwaysfillorreceivetherapyonthedays);forMedicarepatientsittook1.5timesaslong

samedaypayersapprovetheirprescriptions.(10daysvs18).

•Ofthepatientswhowereinitiallyrejected,only57%of•Rejectionsmaybeintendedtomanageutilizationof

Commercialand47%ofStandardMedicareultimatelycostlytherapy,buttheycancausedelaysforpatients

filledtheirtherapywithin365days.startingclinicallynecessarytreatment.

•ForCommercialandMedicarepatientswhowere

approvedontheirfirstattempt,87%and82%ofthem,

respectively,filledtherapywithinoneweekofthe

initialattempt,comparedto54%and64%ofpatients

whowereinitiallyrejected.

Notes:Brandsincludetreatmentsagainstbreast,lymphoma,leukemia,prostate,andnon-smallcelllungcancer;Anyfillwithin365daysofinitialattemptisincluded.

8|AccessChallengesintheCancerPatientJourney

Dispensingsiteeffects

•Patientswhoovercomeaccesshurdlesatretail

pharmaciesareatagreaterriskofwaitingovertwo

Patientscanacquiretheirmedicationsfromanumberof

monthstoinitiatetherapythanthoseatspecialty/mail

differentdispensingsitesandpoints-of-sale.Foroncology

ormedicallyintegratedpharmacies.

patients,theseincludemedicallyintegratedon-site

practicepharmacies,specialty/mailpharmacies,andretail

pharmacies,eachofferinguniqueadvantages.

•Patientsweretwiceaslikelytoabandontherapyat

retailsites(31%Commercial,64%Medicare),while

medicallyintegratedandspecialty/mailpharmacies

Medicallyintegratedpharmacieshavethebenefitof

hadsimilarfillrates(18%Commercial,37%Medicare).

bringingpatients,providers,andpharmaciststogether

inoneplace,facilitatingtheirabilitytoworkthrough

obstaclesliveandin-person.Similarly,specialty/mail

pharmaciesareskilledintheswiftdistributionand

supportofspecialtymedications,suchasoraloncology

•InbothCommercialandMedicare,retailpharmacies

hadthegreatestproportionofcostsabove$250(22%

and70%,respectively)comparedtospecialty/mail(15%,

63%)andmedicallyintegratedpharmacies(15%,58%).

medicines.Retailpharmacies(fromlocalindependentsor

largeretailsupermarkets)canbeplacespatientsfrequent

intheirdailyroutinesandmayprefertouseduetotheir

familiarityandaccessibility.

Pharmacynetworkshavebecomethenorminoncology,

andtheycanbeleveragedasyetanotherformofpayer

controlandutilizationmanagement.Betweenmandated

specialty/mailandmedicallyintegratedpharmacies,our

analysisindicatesbotharelowerriskforprescription

abandonment.

Asthedispensinglandscapeevolves,understandinghow

differentsettingsimpactpatientaccesswillhelptoinform

futureconversationsaroundtheoptimalwaypatientscan

andshouldobtaintheirtherapy.

KEYTAKEAWAYS:

•Patientsatretailpharmaciesfacedthegreatest

proportionofandmostdurablerejectionsacross

pharmacysites.

•Specialty/mailpharmacieshadthegreatestinitial

approvalratesforallnewpatients.

•Despitenothavingthehighestrateofinitialapproval,

medicallyintegratedpharmacieswerejustasefficient

asspecialty/mailpharmaciesinhelpingpatients

overcomerejections.

|9

Patientsfaceheavyinitialrestrictions,butmostmedicallyintegratedandspecialty/mail

rejectionsareultimatelyapproved

Exhibit6:Initialandfinal30-dayclaimstatus,brandedoraloncologytherapy,2020-2023

Commercial

100%

80%

30%

52%

14%

11%

56%

38%

36%

60%

40%

20%

0%

38%13%

11%

46%

13%23%

37%

14%

25%

18%

17%

16%8%11%17%11%

StandardMedicare

8%

InitialFinalInitialFinalInitialFinal

100%

80%

60%

40%

20%

0%

11%

11%

63%

46%

39%

14%

19%

25%

41%

24%

19%

40%

39%50%

21%

41%

14%

20%

InitialFinalInitialFinalInitialFinal

MedicallyintegratedSpecialty/MailRetail

RJ-NotcoveredRJ-PA/StepRJ-AdminAbandonedFilled

Source:IQVIALAADPharmacyClaimsdata,IQVIAMarketAccessStrategyConsultinganalysis

•WithfewerPA/Steprejections,specialty/mail•Patientsatretailpharmacieshadthehardesttime

pharmacieshadthegreatestinitialapprovalratesforovercomingtheirinitialrejections.

newCommercialandMedicarepatients.

•Retailpharmacieshadboththelowestratesofinitial

•Commercialpatientsfacedhighadministrativeandfinalapprovals,withonly36%ofCommercialand

rejectionsacrosssites,whilecontrolforMedicare21%ofMedicarepatientsfillingtheirscripts.

patientstooktheformofPA/Steprejections.

•Overall,medicallyintegratedpharmaciesand

•Regardlessofsite,administrativerejectionsinspecialty/mailpharmacieshadsimilarpatternsof

Commercialweremainlymadeupbyrequirementsfortherapyinitiation.

patientstofillatspecifiedpharmacies.

Notes:Initialclaimstatusisdefinedasapatient’sfirstattempttofillaprescription;finalclaimstatusistheultimateoutcomeoftheclaim30daysaftertheinitialattempt.

Brandsincludetreatmentsagainstbreast,lymphoma,leukemia,prostate,andnon-smallcelllungcancer

10|AccessChallengesintheCancerPatientJourney

Medicarepatientsarequickesttoovercomerejectionsatmedicallyintegratedsites,

whichtook2.5weeksonaverage

Exhibit7:Timeindaysfrominitialrejectiontofillwithin1year,brandedoraloncologytherapy,2020-2023

AvgMedian

M-I

54%19%8%6%7%6%

19Days7Days

SP/Mail19Days6Days

61%16%7%5%5%6%

Retail24Days8Days

47%21%9%7%8%9%

M-I

65%13%6%6%

17Days4Days

SP/Mail

64%13%7%7%

21Days6Days

Retail

54%13%9%9%10%

27Days7Days

0%20%40%60%80%100%

%New-to-brandpatients

0-78-1415-2122-3031-6061+

Source:IQVIALAADPharmacyClaimsdata;U.S.MarketAccessStrategyConsultinganalysis

•Payerrejectionscausequantifiabledelaysintreatment•Mostpatientsovercamerejectionswithinaweekofan

startsandcanvaryacrosspharmacytype.initialattempt,butonaverage,patientswerenotable

•ForCommercialpatients,46%atretailsitesfilledtheir

toinitiatetherapyforatleast2.5weeks.

prescriptionswithinoneyearafteraninitialrejection;•Medicarepatientsinmedicallyintegratedpharmacies

58%atspecialty/mailfilled;and60%atmedicallyovercamerejectionsintheleastamountoftime.

integratedsitesfilled.

•Acrosspayerchannels,thosewhofacedinitial

•Somepatientsworkthroughaccesschallengesattherejectionsatretailpharmaciestookthelongesttimeto

samepharmacylocation,whileothersmayswitchtoainitiatetherapywhileovercomingthosebarriers.

newpharmacyand/orpharmacytype.

•Unlikemedicallyintegratedandspecialty/mail

•ForMedicarepatients,29%atretailsitesfilledtheirpharmacies,retailpharmaciesarelessautomated

prescriptionswithinoneyearafteraninitialrejection;andhavealimitedinfrastructurewhenhandling

44%atspecialty/mailfilled;and53%atmedicallyrestrictionsonpatients’medications.

integratedsitesfilled.

•Medicallyintegratedpharmaciesespeciallybenefit

fromhavingproviderson-site,facilitatingquicker

successthroughrejectionsrequiringproviderinput.

Notes:Brandsincludetreatmentsagainstbreast,lymphoma,leukemia,prostate,andnon-smallcelllungcancer;Anyfillwithin365daysofinitialattemptisincluded.

|11

Patientsabandonatdifferentratesbypharmacytypeandcanreach67%-81%whencostsexceed$250

Exhibit8:Newpatientabandonment,brandedoraloncologytherapy,2020-2023

CommercialStandardMedicare100%

80%

60%

40%

20%

0%

8%

13%

$0

30%

18%

$0.01-

42%

23%

$50-

67%

52%

$250+Overall

31%

18%

15%

2%

10%

$0

53%

12%

$0.01-

45%

17%

$50-

81%

60%

37%

$250+Overall

64%

$49.99$249.99$49.99$249.99

MedicallyintegratedSpecialty/MailRetail

Source:IQVIALAADPharmacyClaimsdata;U.S.MarketAccessStrategyConsultinganalysis

•Patientsareconsideredtohaveabandonedtheir•Additionally,retailsitesmaynothavethe

prescriptionsiftheyhavenotfilledtheirtherapywithinresources—orinventory—tosupportpatientson

90daysofgainingpayerapproval.specialtymedications.

•Retailpharmacieshadthehighestabandonmentrate•Acrossalldispensingsites,increasedpatientcost

regardlessofcost.exposureledtoincreasedabandonment,withover

•31%ofapprovedCommercialpatientsatretail

50%ofpatientsnotfillingprescriptionsover$250.

pharmaciesdidnotfilltheirtreatment,while64%of•Over75%ofallCommercialpatientsfacedcosts

Medicarepatientsabandonedtheirs.below$50,while60%ofallMedicarenew-to-brand

•Increasedabandonmentatretailpharmaciesmaybe

prescriptionshadcostsabove$250.

duetouniquehurdlescharacteristicofretaillocations•Overall,patientswhoattemptedtofillateitherathatcouldincludetransportation,mobility,andtime.medicallyintegratedorSP/mailpharmacysitehad

similarabandonmentrates.

Notes:Brandsincludetreatmentsagainstbreast,lymphoma,leukemia,prostate,andnon-smallcelllungcancer.

12|AccessChallengesintheCancerPatientJourney

Financialsupportinoncology

Duetospecialtytieringandprice-basedcoinsurance,

cancerpatientsmayfacehundredsofdollarsincosts

perprescription.Financialsupportintheformof

manufacturer-sponsoredcopaycardsinCommercial

andcharitablefoundationsinMedicareplayanecessary

roleinoffsettingpatientout-of-pocketcosts,andthus,

facilitatetreatmentinitiation.

Withoutsuchassistance,patientsabandontheir

prescriptionsatagreaterrateanddonotinitiate

treatmentforthemedicinestheywereprescribed.

ForbothCommercialandMedicarepatients,financial

supportcanbecrucialtotherapyinitiationand

maintenance.Patientswithfinancialsupportarealso

morelikelytostayontherapyoverthecourseofayear

thanthosewithout.

StandardMedicarepatientsareespeciallypronetohigh

costsduringthegapphaseofcoverage—aphase