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Background: Monotherapy and combinations of Pembrolizumab (Pembro), Atezolizumab (Atezo) and Cemiplimab (Cemi), prolonged overall survival (OS) in advanced/metastatic non-small cell lung cancer (a/m NSCLC). Pembro demonstrated 5-year OS gain. The duration of therapy of the immune check point inhibitors (ICI) has not been defined. One-year adjuvant Durvalumab (Durv) and Atezo significantly extended OS. Neoadjuvant few cycles resulted in positive outcomes. ICI costs are relatively expensive and multiply with further use with no containment on sight. The 2019 CAR-T cost was limited to $450,000. There are unmet needs for coherent drug cost policies. We aimed 1- Explore the factors which impact ICI costs in lung cancer 2- Navigate cost-saving strategy based on generics, therapy duration 3- Explore the possibility whether adjuvant and neoadjuvant treatment impact costs

Methods: Annual drug prices were quoted and calculated. Utilization thresholds were set for ICI monotherapy at $450,000 and combinations at $550,000.

Results: Estimated annual Pemetrexed (Peme) costs were $113,793, generic chemicals < $1,000 and Bevacizumab (Bev) $150,126. The mean of 6 ICI was $148,000. Pembro 2-year costs were $334,652, below the the proposed $450,000 thresolds. The 3-year costs of $501,978 and the 5-year $836,630 were above $450,000. Atezo + Bev+ Peme combination had the highest 2-year $722,977 costs, above $550,000. There was no significant difference in cost between Atezo + Peme $422,725, Pembro + Peme $448,445 and Cemi + Peme $425,385. These combinations were below the $550,000 threshold. Costs decreased using generics by 25%. Extending ICI use by 6-12 months increased combination costs by 25-50%. Adjuvant 1-year Durv costs were $148,013 and Atezo $154,446, half the 2-year. Using response rates, cost of 2-4 cycles of neoadjuvant Nivolumab (Nivo) were only $25,000 - $50,000.

Conclusion: Generics, limited ICI duration, utilization thresholds and neoadjuvant therapy significantly reduced drug costs. Neoadjuvant therapy had the highest impact on cost reduction.