With increased diagnosis rates and higher drug prices for multiple sclerosis (MS), U.S. health plans have grown more focused on their coverage of and spending on MS therapies. Partly because of the profile of typical MS patients (younger and otherwise healthier than Medicare beneficiaries), private and Medicare plans tend to use different strategies in reimbursing for MS therapies. Private plans cover the therapies we analyze in this report on a lower tier and with fewer restrictions, resulting in increased access to these drugs for beneficiaries. An analysis of commercial and Medicare plans' formulary treatment of beta-interferon (beta-IFN) and other MS therapies shows that Medicare plans, especially larger ones, are aggressively restricting access to top-selling therapies such as Teva's Copaxone (glatiramer acetate), Bayer HealthCare's Betaseron (beta-IFN-1b), and Novartis's Avonex (beta-IFN-1a) through use of higher tiers and increased prior authorization. In addition, both commercial and Medicare plans have started making coverage decisions about the recently launched therapies Acorda Therapeutics/Biogen Idec's Ampyra (dalfampridine) and Novartis's Gilenya (fingolimod); these decisions could augur the market potential of these drugs as well as the prospects for emerging therapies.

A survey of pharmacy directors suggests that plans expect the cost of MS therapies to increase over the next five years, but national plans expect a slower climb or potential decrease as biosimilars enter the market. Health plans are expecting to increase their use of restrictions on existing brands once biosimilar versions of beta-IFNs reach the market (as soon as 2015), potentially affecting the tier status of some top-selling therapies. For emerging therapies, health plans report they will likely reimburse for these therapies, including orally administered ones that may compete with Gilenya. However, the high cost of these agents will likely drive plans to not reimburse for new drugs on an advantaged tier and restrict access to many of them. Surveyed plans do not indicate that they see much differentiation among the new therapies, but their concerns about cost may drive them to reward only a few drugs with better tier placement in exchange for better discounts and rebates.

Using tiering and restrictions data from Fingertip Formulary, as well as insight from 50 pharmacy directors, this report determines the key trends in reimbursement of MS therapies, the drivers of these trends, and how stakeholders can capitalize on future shifts in coverage to steal share from the competition.

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