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Payer Knowledge on Oncology Biomarkers


Kerri Fitzgerald

Tampa—Biomarkers have become an important part of individualized care and targeted therapies. Specifically for oncology, more targeted therapies are receiving FDA approval, with a focus on finding oncology biomarkers that will predict risk, diagnose or classify disease, and/or assess the potential response to therapy of individual patients.

Of the 189 oncology therapies under development between 2012 and 2015, 105 agents (56%) have an associated biomarker. Biomarkers can predict which patients are likely to respond to oncology therapies, which can save patients from unnecessary toxicity, enhance their chance of receiving optimal therapy, control costs, and improve the success rate of clinical drug development.

A. Dandappanavar and colleagues sought to understand payer familiarity with and knowledge of coverage practices regarding oncology biomarkers through a focus group survey. A quantitative survey of a blinded advisory group was conducted on October 15, 2013, via a 15-minute moderated audience-response system survey. A total of 46 managed care advisors who are members of Xcenda’s Managed Care Network participated in the survey.

The results of this survey were presented at the AMCP meeting during a poster session titled Payer Familiarity with Oncology Biomarkers, Their Companion Diagnostics, and Specific Plan Coverage Practices: Results of a Focus Group.

Members of a research panel consisted of payer practitioners; experts from commercial health plans, Medicare Advantage/prescription drug plans, managed Medicaid health plans, and integrated healthcare delivery systems; and pharmacy benefit managers. Xcenda paid the focus group participants an honorarium. One hundred percent participation for all of the questions presented to the focus group was not guaranteed.

The majority of the focus group participants (57%; n=26) were pharmacy directors. The majority of the focus group participants (33% n=15) were part of managed care organization healthcare plans.

When asked how knowledgeable they are about biomarker testing or companion diagnostics in the oncology space, a majority of payers (55%) rated their knowledge as moderate to high. Most of the payers (n=20) were unfamiliar with how often oncology biomarker requests were received and/or approved by their plans.

Most of the payers (n=30) said a request for a required biomarker or diagnostic test for an oncology therapy is frequently approved by their plan. However, the majority of payers (n=17) said they do not know how often a request for an elective biomarker or diagnostic test for an oncology therapy is approved by their plan.

When asked if their plan currently tracks the utilization or overall cost of providing patients with biomarker testing and companion diagnostics for oncology drugs, 73% (n=41) said “no.”

Sixty percent of the payers said that if an oncology therapy requires an elective biomarker or diagnostic test, their plan’s management strategy for covering the biomarker test is to cover the test and the drug separately. Another 34.29% of payers said the drug is covered only if the test results are available prior to starting.

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