BURLINGTON, Mass., Sept. 19, 2016 /PRNewswire/-- Decision Resources Group finds that rheumatoid arthritis (RA) biologics and Xeljanz have widespread coverage on the commercial and Medicare Advantage plans of surveyed managed care organization (MCO) pharmacy directors (PDs)/medical directors (MDs). Among the RA biologics/Xeljanz, the market-leading TNF-alpha inhibitors, Enbrel and Humira, continue to enjoy the most favorable reimbursement profiles in surveyed payers' plans. However, utilization management controls—most commonly, prior authorization and step therapy requirements—are frequently implemented by surveyed payers to restrict the prescription of all high-cost therapies for RA. Consistent with these findings, the majority of rheumatologists who were also surveyed for this research content, indicate that such payer policies impact their prescribing of RA biologics/Xeljanz. The established TNF-alpha inhibitors Enbrel, Humira, and Remicade—the three agents surveyed rheumatologists report most frequently prescribing for RA—are generally less affected by MCO restrictions than the newer TNF-alpha inhibitors Cimzia and Simponi and the novel non-TNF agents (Orencia, Rituxan, Actemra, and Xeljanz). However, marketers of Remicade and Humira may be faced with the challenge of defending their favorable formulary positioning against biosimilars when they become available; roughly one-half of surveyed payers indicated that only the biosimilar versions of infliximab or adalimumab would be covered on their formularies.

Other key findings from the Access & Reimbursement content entitled Rheumatoid Arthritis Access & Reimbursement Overview and Detailed, Expanded Analysis in the US:

  • According to surveyed payers, the net cost of a drug (after rebates and discounts) is the key driver in formulary decisions for RA therapies, followed by efficacy in reducing signs and symptoms of disease.
  • Supported by physician familiarity, long-term safety data, and favorable formulary coverage, the leading TNF-alpha inhibitors, Enbrel and Humira, are most frequently prescribed as first and second-line biologics for commercially-insured RA patients refractory to conventional disease modifying antirheumatic drugs (DMARDs), according to surveyed rheumatologists.
  • Despite its slow start, Xeljanz, the first oral JAK inhibitor approved for RA, has been gaining patient share in the earlier lines of therapy of surveyed rheumatologists, likely owing to growing physician experience and comfort with the agent. Increased market access and reimbursement may have also played a role in the uptake; surveyed payers report that Xeljanz's formulary coverage is similar to or more favorable than the other non-TNF-alpha inhibiting agents.  
  • The majority of surveyed payers anticipate that they will reimburse biosimilars of key RA agents (infliximab, adalimumab, rituximab, abatacept) in their commercial plans within a year of their respective launches.

Comments from Decision Resources Group Analyst Ronnie Yoo, Ph.D.:

  • "Obtaining preferred brand coverage for RA therapies on commercial and Medicare Advantage plans will only continue to become more difficult. As the costs of RA agents continue to climb, payers are likely to impose stricter prescribing controls or take further measures to require patients to obtain these high-cost agents from a specialty pharmacy."
  • "It will be extremely challenging for emerging RA therapies such as baricitinib or sarilumab to achieve premium pricing without sacrificing formulary coverage or favorable tiering, especially with the impending entry of cost-effective biosimilars of the leading TNF-alpha inhibitors."

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About Decision Resources Group

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Media contact:

Jessica Crawford

SOURCE Decision Resources Group

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