With 2014 approaching the halfway mark, health plans are already turning their attention to next year's qualified health plans and that means determining drug formularies for 2015. Payers continual challenge is balancing the need to control costs in the exchange environment with their members ability to get the drugs they need at a cost that does not deter adherence.

Fortunately for payers, some of the highest-use traditional drug classes such as proton pump inhibitors for acid reflex, statins for cholesterol control, and drugs for high blood pressure have had decreases in the pharmacy spend, due to the availability of generics, according to drug trend reports by the nation's top pharmacy benefit managers. Exchange-based drug lists will continue to favor these generic versions.

But for some other diseases, the lack of generic competition is forcing harder choices. One high-use drug class that bears watching is asthma. After hypertension and type 2 diabetes, asthma is expected to be the third-most prevalent condition among exchange-based lives, according to Decision Resources Group's Physician & Payer Forum survey of managed care plans and pulmonologists.

Although PBMs have noted an overall decline in the pharmacy spending trend for asthma drugs (likely because of the generic entry of Singulair, an oral alternative to steroids), the fixed-dose combination inhalers that combine a long-acting beta agonist with an inhaled corticosteroid are still relatively high-priced, having remained free of generic competition, primarily because their inhaler devices are difficult to replicate.

Until patents start expiring in 2016, branded inhalers such Advair, Symbicort, and Dulera continue to jockey for position on formularies. An emerging therapy for asthma is Breo Ellipta, already indicated for chronic obstructive pulmonary disease. It is GlaxoSmithKline's follow-up to Advair and has the advantage against the other ICS/LABA inhalers of requiring a once-daily dose, instead of twice daily.

Intensive competition in the class has required some drug marketers to cough up big rebates to ensure preferred status. That became evident when Express Scripts, the nation's largest PBM, excluded Advair Diskus from its 2014 National Preferred formulary in favor of AstraZeneca's Symbicort.

Health plans are also looking to formulary strategies to keep drug costs under control in the exchanges. To gain insight on payer strategies and physician prescribing habits in relation to asthma in the exchanges, DRG's Physician & Payer Forum surveyed 100 pulmonologists, pharmacy directors, and medical directors from 40 managed care organizations just before the exchange plans took effect in January.

The report focused on not only the combination inhalers, but also on the single inhaled corticosteroid products (such as Flovent, QVAR, and Pulmicort) that are typically prescribed first for long-term asthma control.

The study found that first-to-market, sales-leading brands, particularly Flovent and Advair, maintain the strongest positions in the exchanges. Although they are subject to less-favorable status, they fare better than competitors.

MCO officials indicated they would place more restrictions or increase patient cost-sharing on branded drugs, and that branded ICS and ICS/LABA therapies would be more likely to appear on nonpreferred tiers in exchange-based plans than commercial plans.

For their part, pulmonologists expected exchange plans to be most restrictive on ICS/LABA therapies, likely because they would have patients try and fail first on an ICS monotherapy, such as Flovent. Although they anticipated slightly decreasing their prescribing of ICS/LABA branded drugs for exchange patients, particularly for Advair, the physicians indicated their prescribing will not vary greatly for patients in commercial versus exchange-based plans.

In terms of covering emerging therapies, MCOs indicated they are more motivated by drug costs than outcomes. Assuming Breo's approval for asthma indication in 2014, most MCO pharmacy and medical directors expected Breo to be placed on Tier 3, although almost as many forecast coverage on preferred tiers. Exchange-based coverage would be less generous in exchange plans than commercial. Despite less favorable coverage in the exchanges, 64 percent of pulmonologists reported they would not reduce their prescribing of the drug. But they would be nearly twice as likely to prescribe it if it were on a preferred tier.

One way drug marketers have responded is by offering insured members coupons that offset the copay or coinsurance on branded drugs. Although the jury is still out on whether the federal government will allow coupon use in the exchanges, GSK and Merck have suspended marketing these in the exchanges until there is more clarity. But according to the DRG survey, even though MCOs would restrict access to coupon-associated drugs though step therapy, prior authorization, and higher tiering, few would exclude these drugs from coverage.

If the survey holds true, exchange formularies will continue to support the most popular branded asthma inhalers for at least another year, although step therapy requirements and cost sharing may limit their use in exchanges more so than commercial formularies.

It has not been easy to fully assess the actual 2014 impacts from exchange formularies; drug lists have not been easy to find, and the lack of consistency makes comparisons difficult. A lot of that will change in 2015, as the federal government is requiring qualified health plans to link consumers directly to the formularies where they can see drugs covered by tier. Hopefully, at least knowing the status of these important drugs will enable asthma suffers to breathe a little easier.

Follow Chris Lewis on Twitter @ChrisLewisDRG


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