Rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) are chronic and, in many cases, debilitating diseases requiring lifelong treatment. Costs associated with biologic treatment for RA patients not successfully managed on conventional disease-modifying antirheumatic drugs (DMARDs) can be in excess of $30,000 per year. In the effort to curb escalating drug costs associated with treating these chronic, progressive conditions, many health insurers have turned to narrow provider network arrangements and clinical pathways that encourage prescribers to use preferred agents and to achieve cost-control targets. This report focuses on the effect of narrow provider networks and clinical pathways on the use of branded drugs treating moderate to severe RA and SLE. RA is a crowded category of branded biologic drugs, led by three of the longest-used biologic agents: etanercept (Amgen/Pfizer‘s Enbrel), infliximab (Janssen’s Remicade), and adalimumab (AbbVie’s Humira)—all TNF-alpha inhibitors. More-recent agents studied include certolizumab pegol (UCB’s Cimzia),  tocilizumab, (Roche’s Actemra), abatacept (Bristol-Myers Squibb’s Orencia), and rituximab (Biogen Idec/Roche’s Rituxan). An oral nonbiologic, tofacitinib (Pfizer’s Xeljanz), is the most recent arrival on the market (2012).  Treatment of advanced SLE includes off-label use of DMARDs including Genentech’s CellCept and the B-cell modulator Rituxan, as well as a relatively new rheumatologic agent, belimumab (GlaxoSmithKline’s Benlysta).

Questions Answered:

  • Clinical pathways—which identify preferred drugs for use at each stage of treatment—are mostly known for their use in oncology indications; however, some health plans and providers are also using pathways for RA and SLE, and many anticipate doing so within the next ten years. What outcomes related to clinical pathways have been noted by payers that have used them for autoimmune conditions? How do plans encourage physicians to follow clinical pathways and what is the average targeted compliance rate? What attributes of a drug are important to payers and physicians when determining which drugs should be included in pathways?
  • Survey results show that clinical pathways often follow the step therapy profile of the insured member’s health plan. What are the most common restrictions on RA and SLE drugs imposed by payers? What are the successes and stumbles of specific drugs to treat these conditions, based on physicians’ reactions to access and reimbursement issues?
  •  Narrow networks—a network of healthcare providers that is a smaller subset of a broader provider network—have become a familiar feature in low-cost health plans for individuals and small groups. How do managed care organizations (MCOs) select rheumatologists to participate in their narrow networks and what conditions must they meet to stay in these networks? What impacts on prescribing patterns do MCO officials expect to result from narrow network participation, and what are the actual impacts as reported by rheumatologists for drugs treating RA and SLE? Are separate formularies used for narrow network plans?


Markets covered: United States.

Primary research: Online survey of 101 rheumatologists, 37 MCO medical directors, and 26 MCO pharmacy directors.

Commercial context: Epidemiology tables, drug-treatment algorithms, and managed care background information.

Therapies covered: Drugs used for the treatment of RA and SLE in the following categories: TNF-alpha inhibitors, B-cell-targeted therapies, selective costimulation moderators, IL-6 inhibitors, IL-1 inhibitors, and Jak inhibitors.”

Table of contents

  • Detailed, Expanded Analysis Rheumatoid Arthritis and Systemic Lupus Erythematosus (US)
    • Actionable Recommendations to Optimize Market Access
      • Actionable Recommendations to Optimize Market Access for New RA and SLE Therapies in the US
    • Successes and Stumbles
      • United States: Reimbursement Successes and Stumbles
    • Key Stakeholders in the Road to Market Access
      • Key Stakeholders in the Path to Formulary Access
      • Stakeholder Dynamics in the Road to Reimbursement
    • Key Market Access Roadblocks
      • Key Market Access Roadblocks for RA and SLE Therapies
    • Reimbursement Dynamics
      • United States: Commercial Managed Care Organizations
        • Reimbursement Summary
        • Formulary Inclusion Drivers
        • Pricing and Reimbursement Drivers
        • Restrictions and Prior Authorizations
        • Narrow Network Requirements for Rheumatologists
    • Pricing and Reimbursement, Policy, and Coverage: Impact on Prescribing
      • Patient Share in Key Payer Channel
        • Patient Share: RA Drugs
        • Patient Share: SLE Drugs
        • Top Prescribing Drivers: Autoimmune Drugs in Pathways
      • Prescriber Preference
      • Impact of Payer Policy on Prescribing
        • Impact of Payer Restrictions on Prescribing for RA
    • Methodology
      • Primary Market Research Methodology - Physicians
        • Physician Demographics
      • Primary Market Research Methodology - MCOs
        • MCO Demographics
    • Appendix
      • Physician Survey
        • Attainment of Compliance Rate Targets in Clinical Pathways
      • MCO Survey
      • Additional Information
        • Narrow Networks and Clinical Pathways: Results and Metrics
        • MCO Reimbursement for Drugs Treating SLE
        • Use of Dedicated Formularies Within Narrow Network Plans
        • Impact of Payer Restrictions on Prescribing for SLE
      • Commercial Context
        • Epidemiology
        • Treatment Algorithm for RA
        • Treatment Algorithm for SLE
        • Annual Cost of Therapy for RA Biologics, 2014

Author(s): Paula Wade

Paula Wade tracks and analyses the national trends in the health insurance industry for Decision Resources Group. She produces the company’s Managed Care Organization Analyzer products and has authored several of DRG’s Physician Payer Dynamics reports. A former newspaper journalist with a background in survey research, Ms. Wade has also worked in healthcare advocacy and for the Tennessee Department of Commerce and Insurance.

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