# NSCLC Specialty Pharmacy Comparison **Researcher Agent Output • Independent Analysis • January 4, 2026** ## Same Drug. Different Pharmacy. Different Outcome. *And now we have the data to see the gap.* ### Hero metrics | Value | Label | Detail | |-------|--------|--------| | 7.5pp | Persistence Gap | Between major SPs | | 8 days | Earlier Refills | Top SP ships sooner | | 75% | Still Medically Active | Among non-persistent patients | ## The SP Performance Gap Specialty pharmacy is table stakes for oral oncology. Most targeted therapies have limited distribution networks. The prescription goes to an SP, and the assumption is: infrastructure is in place, copay support is enrolled, refill management happens. But when we compared the two largest PBM-owned specialty pharmacies—same drug class, same payer type, commercially insured patients only—we found a measurable performance gap. ## Performance Comparison Same drugs. Same payer type. Different operations. Different outcomes. *N = 1,907 (Top SP) vs. 2,334 (Comparison SP), commercially insured patients.* | Metric | Top SP | Comparison SP | Gap | |--------|--------|---------------|-----| | 6-month persistence | 72.2% | 64.7% | 7.5pp | | Proactive refill timing | 10 days early | 2 days early | 8 days | | Refill gaps >7 days | 4.1% | 9.7% | 2.4× | *Cohorts are comparable on line of therapy (95.7% vs 94.8% 1L) and comorbidity (RAF 28.8 vs 30.0). The gap isn't patient mix.* **What we measured:** The top SP gets refills to patients 10 days before they run out. The other: 2 days. We don't know if it's auto-refill, proactive calls, or faster shipping. We know the timing. We don't know the mechanism. --- ## Sensitivity Analysis The gap replicates across drug classes, payer types, and patient ages. This isn't noise. | Subgroup | Top SP | Comparison SP | Gap | |----------|--------|---------------|-----| | EGFR inhibitors | 72.1% | 65.0% | 7.1pp | | ALK inhibitors | 75.6% | 67.1% | 8.5pp | | Age <65 | 74.3% | 66.5% | 7.8pp | | Age 65-74 | 68.8% | 62.1% | 6.7pp | *Gap remains stable (6.7–8.5pp) regardless of drug biology or patient age.* ## Non-Persistence is Not Mortality Among patients who fail to persist at 6 months, **75% show continued medical activity** in months 7-12. Among those discontinuers, more remain medically active at 12 months at the Top SP than at the Comparison SP (83.7% vs 70.6%). The pharmacy with better persistence is also losing healthier patients—the pattern you'd expect from an operational gap, not patient selection. This pattern isn't consistent with uniform disease progression. The data points to an operational gap—and operational gaps are addressable. ## Payer Policy is the Upstream Lever Prescribers don't fully control pharmacy routing for limited-distribution drugs. Payer policy does. | | Major PBM A | Major PBM B | |--|-------------|-------------| | Lives with SP mandate | 60% | <1% | Before optimizing SP performance, you need to understand which payer networks your patients sit in—and what those networks allow. Note: patients at mandated vs. non-mandated SPs may differ in ways we can't measure. The policy gap is context, not causation. *Beyond payer mandates, we also had to make decisions about what to include in our SP comparison.* ## What We Excluded (And Why) Beyond major SPs, 57% of patients filled at smaller specialty pharmacies or health system dispensaries. Persistence there is lower—but interpretation is messier. **Hospital outpatient pharmacies showed 24.7% persistence**—almost certainly confounded by patient severity and clinical trial enrollment. We excluded them from any intervention framing. --- ## What This Means for Your Brand This analysis benchmarked SP performance at the therapeutic class level. For clients, we go deeper: 1. **SP Performance Benchmarks** — Which of your contracted SPs is outperforming? What operational metrics explain the gap? 2. **Payer Policy Mapping** — Which PBMs mandate specialty dispensing for your drug? Where's the network leakage? 3. **Drug-Specific Channel Analysis** — What does "fragmented channel" actually mean for your specific distribution network? 4. **Intervention Sizing** — How many patients are in the addressable gap? What's a realistic impact estimate? ### Estimated Impact **One brand. One SP pair. $12–18M.** 150–200 additional persistent patients, representing $12–18M in additional therapy revenue at current pricing. This is a directional estimate; actual impact depends on drug mix, pricing, and discontinuation reasons. This models only the gap between the two largest specialty pharmacies. Broader channel optimization—the 57% of patients at smaller pharmacies—is not included. ### Methodology - Open medical + pharmacy claims on 330M+ lives - Formulary data provided by MMIT - Cohort: Lung malignancy + oral therapy, 2022-2025 - EGFR, ALK, KRAS, MET, RET, ROS1 inhibitors - Persistence: Refill activity days 150-210 - NPI taxonomy with manual validation ### Limitations - Observational—patients may differ unmeasurably - Refill timing is suggestive, not causal - Hospital patients excluded (confounding) - Findings blinded; can de-blind in engagement - NSCLC only; cross-TA replication on roadmap --- This is independent research. No manufacturer funded this analysis. 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