Two of the largest pharmacy benefits managers (PBMs) in the United States, Express Scripts and CVS Health, have set traditional U.S. drug reimbursement on its head by introducing indication-specific pricing. Instead of reimbursing a drug the same way across all indications for which it is approved, these PBMs have set up programs to vary reimbursement and formulary placement of some drugs based on their clinical value in different indications or patient subpopulations. This study examines the potential for this strategy to take hold with managed care organizations (MCOs), particularly for coverage of autoimmune drugs, one of the biggest drivers of pharmacy costs for U.S. payers. This game-changing strategy means that rheumatoid arthritis (RA) blockbusters such as Enbrel and Humira could face more competition from lesser-known niche products in certain autoimmune indications, such as psoriatic arthritis (PsA).


  • What is the future for indication-specific pricing in the autoimmune category and are any MCOs employing this strategy now?
  • What are or will be the major challenges involved in varying pricing and/or coverage by indication?
  • What indications do MCOs believe would be appropriate for a variable reimbursement strategy and how would they assess value?
  • Do physicians perceive autoimmune drugs as having a different value for different indications that would make them good candidates for indication-based pricing?


Access & Reimbursement: Provides in-depth insight regarding the impact of payer policy on physician prescribing behavior so you can build your market access strategy and optimize your brand positioning.

Table of contents

  • Detailed, Expanded Analysis: Rheumatoid Arthritis and Psoriatic Arthritis (US)
    • Market Access Overview
    • Actionable Recommendations to Optimize Market Access
      • Actionable Recommendations to Optimize Market Access
    • Successes and Stumbles
      • Overview of Successes and Stumbles for RA and PsA
      • Successes Among RA and PsA Therapies in the United States: Physicians
      • Stumbles Among RA and PsA Therapies in the United States: Physicians
      • Successes Among RA and PsA Therapies in the United States: MCOs
      • Stumbles Among RA and PsA Therapies in the United States: MCOs
    • Key Stakeholders in the Road to Market Access
      • Key Stakeholders in the Road to Market Access
      • United States: Stakeholder Dynamics in the Road to Reimbursement
      • Healthcare Coverage in the United States
    • Key Market Access Roadblocks
      • Key Market Access Roadblocks
    • Reimbursement Dynamics
      • United States: Commercial Managed Care Organizations
        • Reimbursement Implications of Indication-Specific Pricing
        • Pricing, Reimbursement, and Value Drivers for RA and PsA
        • Cost-Sharing and Restrictions
    • Pricing and Reimbursement, Policy, and Coverage: Impact on Prescribing
      • Patient Share in Key Payer Channel
        • Key Findings
        • Treatment Decision Drivers
      • Prescriber Preference
        • Prescriber Preferences for RA and PsA
      • Impact of Restrictions on Prescribing
        • Payer Policy Impact on Prescribing - Key Findings
      • Indication-Specific Pricing: Physicians
        • Key Findings
    • Market Access Landscape for Emerging Therapies
      • Impact of Emerging Therapies on Prescribing
        • Likely Impact of Emerging Therapies for RA and PsA
      • Payer Treatment of New Therapy Approvals in PsA
        • Payer Treatment of New Therapy Approvals for PsA
      • Prescriber and MCO Priorities for Emerging Therapy Evaluation
        • Key Findings
    • Methodology
      • Primary Market Research Methodology: Physicians
        • Physician Demographics
      • Primary Market Research Methodology: MCOs
        • MCO Demographics
    • Appendix
      • Physician Survey
      • MCO Survey

Author(s): William J. Melville Jr

Mr. Melville is Managed Market Insights expert on health insurance exchanges and Medicare. He provides state and market-level analysis in Colorado, Nevada, New Mexico and other states. He has been quoted in the Wall Street Journal, Bloomberg News, Connecticut Mirror, USA Today, Pittsburg Post-Gazette, the Tennessean, and numerous industry publications including Inside Health Policy and RevCycle Intelligence. Melville joined DRG in May 2007. Mr. Melville was previously a commentary editor, associate editor and reporter for Suburban News Publications, a chain of 22 weekly papers in Columbus, Ohio from 1999 to 2007. He graduated from Mercyhurst College in 1999 with a bachelor’s degree in English, minor in political science and was winner of the President’s Award for Excellence for the Humanities Division.

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