Despite the availability of multiple oral atypical antipsychotics in the United States, long-acting depot formulations of atypical antipsychotics offer a compelling advantage because of their less frequent dosing schedules and the associated potential for increased patient compliance, reduced rate of hospitalizations, and overall lower cost of care. Largely due to the availability of these less expensive oral therapies, depot atypical antipsychotics are typically reserved for late lines of therapy and often are subject to reimbursement restrictions that hinder their access. Given that generic versions of some depot agents are expected to launch in the United States in the coming years (e.g., Janssen’s Risperdal Consta), branded depot agents may become even more difficult to access. Emerging depot antipsychotics will need to offer unique benefits to gain a foothold in this market.

Questions Answered:

  • What is the coverage status of depot atypical antipsychotic agents on Medicaid and commercial healthcare plans, including the most recently approved drugs (e.g., Alkermes’s Aristada, Janssen’s Invega Trinza)?
  • How do reimbursement restrictions impact psychiatrists’ prescribing of depot atypical antipsychotics to their schizophrenia patients, and what distribution channels are used to access these therapies?
  • How do payers anticipate that generic versions of depot atypical antipsychotics will impact access to the branded originator therapies? How do psychiatrists expect to prescribe these generics?
  • How do psychiatrists anticipate prescribing emerging depot antipsychotic agents (e.g., Indivior’s RBP-7000), and how do payers expect to cover these therapies at various price points on commercial health plans?

Product Description:

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

  • Schizophrenia - Access & Reimbursement - Detailed, Expanded Analysis (US): Depot Antipsychotic Use
    • Key Updates
      • November 2017
      • Market Access Overview
        • Actionable Recommendations to Optimize Market Access
          • Successes and Stumbles
            • Overview of Successes and Stumbles for Schizophrenia
            • Successes Among Schizophrenia Therapies in the United States: Physicians
            • Stumbles Among Schizophrenia Therapies in the United States: Physicians
            • Psychiatrists' Reported Best-Performing Drugs in Terms of Market Access Themes
            • Psychiatrists' Reported Overall Winner on Market Access Issues
            • Successes Among Schizophrenia Therapies in the United States: MCOs
            • Stumbles Among Schizophrenia Therapies in the United States: MCOs
            • Payers' Reported Best-Performing Drug on Select Clinical and Market Access Factors
          • Key Stakeholders in the Road to Market Access
            • Stakeholder Influence on Physician Prescribing
            • United States: Stakeholder Dynamics in the Road to Reimbursement
            • Healthcare Coverage in the United States
            • Healthcare Coverage in United States
            • Major Commercial Insurers in the United States
            • Psychiatrists' Projected Impact of the ACA's Medicaid Expansion Program's Rollback on Their Patients' Drug Use
          • Key Market Access Roadblocks
            • Reimbursement Dynamics
              • United States: Commercial Managed Care Organizations
                • Lessons Learned and Key Takeaways
                • Current Reimbursement of Atypical Antipsychotic Depots Treating Schizophrenia on MCOs' Commercial Plans
                • Current Reimbursement of Select Generic Typical Antipsychotic Depots Treating Schizophrenia on MCOs' Commercial Plans
                • Current Reimbursement of Select Antipsychotic Depots Treating Schizophrenia on MCOs' Medicaid Plans
                • Reimbursement of Select Atypical Antipsychotic Depots Treating Schizophrenia in 12 Months Time on MCOs' Commercial Plans
                • Reimbursement of Select Generic Typical Antipsychotic Depots Treating Schizophrenia in 12 Months Time on MCOs' Commercial Plans
                • Pricing and Reimbursement Drivers
                • Key Findings: Pricing and Reimbursement
                • Drivers of Formulary Placement and Reimbursement for Schizophrenia's Depot Antipsychotics
                • Value Assessment and Pharmacoeconomics
                • Contracting for Schizophrenia
                • Cost Sharing for Key Therapies Treating Schizophrenia
                • Coinsurance Rates for Select Depot Antipsychotics Covered Under the Pharmacy Benefit
                • Coinsurance Rates for Select Depot Antipsychotics Covered Under the Medical Benefit
                • Copayment Rates for Select Depot Antipsychotics Covered Under the Pharmacy Benefit
                • Copayment Rates for Select Depot Antipsychotics Covered Under the Medical Benefit
                • Restrictions Affecting Treatment of Schizophrenia
                • Restrictions Used in Commercial Plans
                • Impact of Prior Authorization
                • Prior Authorization for Atypical Antipsychotic Depots on Commercial Plans
            • Pricing and Reimbursement, Policy, and Coverage: Impact on Prescribing
              • Patient Share in Key Payer Channel
                • Key Findings
                • Patient Share for Schizophrenia Among Commercially Insured and Medicaid-Insured Patients
                • Treatment Decision Drivers
                • Factors Affecting the Choice of an Atypical Antipsychotic Depot for the Treatment of Schizophrenia
                • Factors That Drive Psychiatrists' Selection of an Atypical Antipsychotic Depot Versus a Typical Antipsychotic Depot
              • Prescriber Preference
                • Potential Changes in Prescribing Absent Payer Restrictions
                • Prescribing vs. Preference
              • Impact of Restrictions on Prescribing
                • Payer Policy Impact on Prescribing: Key Findings
                • Physician-Reported Most Important Restrictions
            • Market Access Landscape for Emerging Therapies
              • Impact of Emerging Therapies on Prescribing
                • Likely Impact of Emerging Therapies for Schizophrenia
                • Patient Share for Branded and Generic Therapies If Emerging Agents Are on Preferred vs. Nonpreferred Tier
                • Likely Impact of Generic Atypical Antipsychotic Depots for Schizophrenia
              • Potential Placement of Emerging Therapy at Various Prices
                • Potential Reimbursement of Emerging Therapies for Schizophrenia
                • Potential Placement of RBP-7000 at Various Price Points
                • Potential Placement of BB-0817 at Various Price Points
                • Projected Impact of Select Generic Atypical Antipsychotic Depots on Branded Atypical Antipsychotic Depots' Formulary Placement and Restrictions
              • Prescriber and MCO Priorities for Emerging Therapy Evaluation
                • Key Findings
                • Areas for Future Opportunity for Atypical Antipsychotic Depots Within the Schizophrenia Market: MCOs
                • Areas for Future Opportunity for Atypical Antipsychotics Depots Within the Schizophrenia Market: Psychiatrists
            • Methodology
              • Primary Market Research Methodology: Physicians
                • Average Years in Clinical Practice
                • Average Numbers of Schizophrenia Patients Treated Per Month
                • Psychiatrists' Practice Location by Region
                • Schizophrenia Patients' Insurance Type
                • Psychiatrists' Practice Location by State
                • Psychiatrists' Type of Primary Clinical Practice
              • Primary Market Research Methodology: MCOs
                • Distribution of Surveyed Medical Directors and Pharmacy Directors
                • Distribution of MCOs' MDs/PDs by Region
                • Distribution of MCOs MDs/PDs by State
                • MCOs' Type of Operations
                • Type of Insurance Plans Offered by MCOs
                • Mean Number of Covered Lives
                • Payers' Level of Familiarity with Their MCOs' Coverage of Depot Antipsychotics for the Treatment of Schizophrenia
            • Appendix
              • Key Abbreviations Related to Schizophrenia
              • Schizophrenia Bibliography
              • Physician Survey
                • Psychiatrists' Reported Best-Performing Drugs in Terms of Clinical Factors
                • Percentage of Diagnosed Patients with Schizophrenia Receiving Pharmacological Treatments
                • Percentage of Diagnosed Patients with Schizophrenia Receiving Depot Antipsychotics
                • Percentage of Diagnosed Patients with Schizophrenia Presenting with Each Symptom Domain
                • Reasons Why Diagnosed Patients with Schizophrenia Refuse Pharmacological Treatments
                • Percentage of Treatment-Resistant Schizophrenia Patients
                • Percentage of Treatment-Resistant Schizophrenia Patients Who Receive Depot Antipsychotics
                • Main Distribution Channels from Where Psychiatrists' Commercially Insured Schizophrenia Patients Obtain Atypical Antipsychotic Depots
                • Percentage of Patients Diagnosed with Negative Symptoms and/or CIAS Who Receive Depot Antipsychotics
                • Reasons Why Psychiatrists Do Not Prescribe Depot Antipsychotic for Negative Symptoms and/or CIAS
                • Percentage of Psychiatrists Who Prescribe Depot Antipsychotics to Their Patients with Schizophrenia
                • Market Access Hurdles Psychiatrists Commonly Face When Switching Patients to and from Atypical Antipsychotic Depots
                • Access and Reimbursement Hurdles' Impact on Psychiatrists' Prescribing of Evaluated Depot Antipsychotics
                • Hurdles Psychiatrists Commonly Face Through Buy and Bill
                • Influence of Out-of-Pocket Costs on the Selection of an Atypical Antipsychotic Depot
                • Percentage of Psychiatrists Who Would Expect to Switch Their Schizophrenia Patients to a Generic Atypical Antipsychotic Depot, by Drug
                • Situations That Would Cause Psychiatrists to Prescribe a Generic Atypical Antipsychotic Depot, by Drug
                • Impact of Aristada's Once-Every-Two-Months Dosing Scheduling on Psychiatrists' Prescribing of Aristada
                • Reasons Why Psychiatrists Expect Their Prescribing of Aristada to Increase
                • Percentage of Patients with Schizophrenia Who Would Receive RBP-7000 by Insurance Plan
                • Projected Placement of RBP-7000 in the Schizophrenia Treatment Paradigm by Insurance Plan
                • Reasons Why Psychiatrists Would Not Prescribe RBP-7000
                • Percentage of Schizophrenia Patients Who Would Receive BB-0817 by Insurance Plan
                • Percentage of Schizophrenia Patients Who Would Receive Risperidone-ISM by Insurance Plan
                • Antipsychotics Likely to Be Replaced by RBP-7000, BB-0817, and Risperidone-ISM
                • Psychiatrists' Preferred Method of Delivery for Depot Antipsychotics
              • MCO Survey
                • Source of Formulary Development and Maintenance for Commercial Plans
                • Type of Formulary Implemented by an External PBM
                • MCOs' Level of Formulary Customization for Commercial Plans
                • Current and Future Status of Commercial Therapies Within the Next 12 Months
                • P&T Committee Time to Review and Rule on a New Product
                • Most Influential P&T Committee Members
                • Materials Required for a P&T Committee Depot Antipsychotic Review
                • MCOs' Coverage of Depot Antipsychotics on Their Medicaid Plans
                • Reasons Why Select Depot Antipsychotics Are Excluded or NDC Blocked from MCOs' Commercial Plans
                • Use of Preferred and Nonpreferred Tiering for Branded and Generic Depots on Commercial Plans' Formularies
                • Factors That Influence an Antipsychotic Depot's Placement Under the Medical or Pharmacy Benefit
                • MCOs' Coverage of Select Depot Antipsychotics on the Pharmacy Benefit and the Medical Benefit for Commercial Plans
                • Percentage of Payers Who Expect to Move Select Atypical Antipsychotic Depots from the Medical Benefit to Pharmacy Benefit
                • MCOs' Reasons for Moving Antipsychotic Depots to the Pharmacy Benefit Only
                • Projected Change in Nonspecialty Tiering for Branded and Generic Depots on MCOs' Commercial Plans in the Next 12 Months
                • Clinical and Market Access Factors That Would Result in Improved Formulary Coverage for Select Atypical Antipsychotic Depots
                • Interim Status Applied to a Recently FDA-Approved Antipsychotic Depot for Schizophrenia Prior to Formulary Review for MCOs' Commercial and Medicaid Plans
                • Preferred Comparator Antipsychotics for Emerging Therapies in Development for the Treatment of Schizophrenia
                • Emerging Therapies with the Greatest Potential Impact on the Treatment of Schizophrenia
                • Average Rebates That MCOs Collect on Their Commercial Plan for Select Atypical Antipsychotic Depots
                • Types of Contracting Agreements in Place for Select Atypical Antipsychotic Depots
                • Average Number of Schizophrenia Patients Needed to Use a Cost-Utility Model
                • Compelling Pharmacoeconomic Data for a New Atypical Antipsychotic Depot
                • Payers' Preferred Model for Examining Cost-Effectiveness
                • MCOs' Use of Deductibles for Commercial Insurance Plans
                • Average Amount of a Brand-Name Deductible for Commercial Plans
                • MCOs' Requirement for Patients on Commercial Plans to Demonstrate Prior Stabilization on an Oral Atypical Antipsychotic Before Treatment with an Atypical Antipsychotic Depot
                • MCOs' Main Distribution Channels for Select Depot Atypical Antipsychotics Covered on Commercial Plans
                • Distribution of "White Bagging" and "Brown Bagging" for Select Depot Atypical Antipsychotics on Commercial Plans
                • Cost Sharing for Select Depot Antipsychotics Covered Under the Medical Benefit
                • Restrictions Used for Atypical Antipsychotic Depots on Commercial Plans
                • Restrictions Used for Atypical Antipsychotic Depots on Medicaid Plans
                • Step Therapy for Atypical Antipsychotic Depots on Commercial Plans
                • MCOs' Requirement for Patients on Commercial Plans to Demonstrate Prior Stabilization on an Oral Atypical Antipsychotic Before Treatment with an Atypical Antipsychotic Depot
                • MCOs’ Requirement for Patients on Commercial Plans to Demonstrate Prior Stabilization on Invega Sustenna Before Treatment with Invega Trinza
                • Potential Impact of Aristada's Once-Every-Two-Months Dosing Schedule on Its Formulary Placement and Reimbursement
                • Cost-Containment Measures Potentially Applied to RBP-7000
                • MCOs' Level of Exclusion of BB-0817
                • Factors That Would Drive MCOs' Inclusion of Risperidone-ISM on Their Commercial Plans' Formularies
                • Impact of the Genericization of the Atypical Antipsychotic Depot Market on the Branded Depots' Formulary Placement and Restrictions Under Commercial Plans
                • Impact of the Genericization of the Atypical Antipsychotic Depot Market on the Branded Depots' Formulary Placement and Restrictions on Medicaid Plans

          Author(s): Lisa Cloonan, BA

          Lisa joined Decision Resources Group in 2015 as a business insights analyst for the Central Nervous System and Ophthalmology division. In this role, she analyzes the commercial opportunities for pharmacological therapies across the psychiatry space.

          Prior to joining Decision Resources Group, Lisa spent 6 years in clinical stroke research at Massachusetts General Hospital. While in the clinical research field, Lisa developed an expertise in neuroimaging analysis, as well as authored and co-authored articles on the influence of white matter hyperintensity burden on stroke risk and recovery. Lisa holds bachelor of arts from Connecticut College, where her course work focused on behavioral neuroscience.


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