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The immune check point inhibitors (ICI) and target therapy (TT) Osimertinib (Osi) prolonged survival in advanced/metastatic non-small cell lung cancer (a/m-NSCLC). Costs of ICI were previously investigated (ESMED, July 2022) while TT being overlooked. In 2022, insulin monthly cost was capped at $35 for Medicare patients. We aimed to 1- Attach a $ amount to results of the major relevant TT and ICI clinical studies and weigh their relative costs 2- Reason that utilization threshold caps are necessary to contain cost of extended therapy

Methods: In this prospective observational study, annual costs of the approved and widely used TT were calculated as the monthly optimal dose x 12.  Costs of the 5-approved ICI in 1-st-line a/m NSCLC were calculated as mg/m2 or per 80 kg x price x number of cycles.

Results: Median annual 5-TT cost was $228,000 vs 5-ICI of $134,786 at 1.69 ratio. At 10%, estimated coverage of pharmacy and nursing costs, ratio dropped to 1.52. The 1-3-year Osi costs were $248,372-$745,116, Crizotinib $226,308 -$678,924 and Larotrectinib $399,372-$1,198,116. Pembrolizumab were $134,796-$404,388, Atezolizumab $124,761-$374,283 and Cemiplimab $125,108-$375,324.

Applying $500,000 caps, the ICI 3-year costs were all below threshold. TT medium 3-year cost was $684,000, exceeding cap by $184,000, Osi by $245,116 and Crizotinib by $178,924. Larotrectinib 2-3-year costs were higher by $298,744 - $698,116. We reasoned that if 1,000 US patients treated with TT at the annual median, cost mounts to $684,000,000. In Europe, 2,000 patients’ cost would be $1,368,000,000.

Conclusions: The median TT/ICI was more costly at 1.52 ratio. Drug costs were determined by the number of re-purchases, the 1^st-buy, if followed, was considered a down payment. Cap implementations are necessary to contain costs of extended therapy.