Formulary Advantages in Immune Biologic Therapies: Health plans’ support for certain drug attributes drive formulary coverage for immune biologic brands

Publish date: June 2011

The market for immune biologics has grown increasingly crowded in recent years with the launches of newer brands such as Simponi, Cimzia, and Stelara looking to take share away from longer-marketed products such as the TNF-alpha inhibitors Enbrel and Humira, as well as Remicade. Despite some of the advantages of newer therapies, commercial and Medicare plans continue to favor longer-marketed products that have known efficacy and safety/tolerability track records. Tiering data from Fingertip Formulary show that health plans have increased their advantaged tier coverage (Tier 1 or 2 placement) for some of these newer therapies in the past year, but plans continue to offer the best tier positions to the longer-marketed brands. Importantly, surveyed health plans report that increased spending on prescription drugs for rheumatoid arthritis, Crohn's disease, and psoriasis over the past five years have not resulted in flat or lower costs for non-drug (i.e., medical) expenses. This finding suggests that plans are not seeing the desired results for greater prescription drug costs and may make them more interested in TNF-alpha inhibitors and drugs that feature an alternative mechanism of action (MOA) that can reduce medical costs. 26% of surveyed plans report that they favor a single TNF-alpha inhibitor brand for treating RA, and they are split between Enbrel and Humira. A survey of pharmacy directors resulted in similar findings for therapies with an alternative MOA.