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).

QUESTIONS ANSWERED

  • 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?

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

  • Rheumatoid Arthritis - Access & Reimbursement - Detailed, Expanded Analysis: Rheumatoid Arthritis And Psoriatic Arthritis (US)
    • Market Access Overview
      • 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
          • Best Performing RA Drug in Terms of Market Access Themes
          • Best Performing PsA Drug in Terms of Market Access Themes
          • 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
          • Physician Assignment of Stakeholder Influence on Prescribing of RA and PsA Drugs
          • 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
        • Key Market Access Roadblocks
          • Reimbursement Dynamics
            • United States: Commercial Managed Care Organizations
              • Current Reimbursement of RA and PsA Therapies
              • Reimbursement of Select RA and PsA Therapies in Largest Commercial Plans
              • Indication Specific Pricing: Key Takeaways
              • Status of ISP Implementation Among Surveyed MCOs
              • Future Implementation of ISP Among Surveyed MCOs
              • Biggest Challenges of ISP Implementation Facing MCOs
              • Feasibility of Overcoming Obstacles to Future ISP Adoption
              • Pricing and Reimbursement Drivers
              • Key Findings: Pricing and Reimbursement
              • Value Determination of Autoimmune Therapies in Indication-Based Pricing
              • Cost-Sharing for Key Therapies Treating RA and PsA
              • Average Coinsurance for RA and PsA Drugs
              • Median Copayment for RA and PsA Drugs
              • Restrictions Affecting Treatment of RA and PsA
              • Restrictions Used in Commercial Plans
              • Impact of Prior Authorization for RA Drugs
              • Impact of Prior Authorization for PsA Drugs
          • Pricing and Reimbursement, Policy, and Coverage: Impact on Prescribing
            • Patient Share in Key Payer Channel
              • Key Findings
              • Patient Share for RA Biologics/Jak Inhibitors Among Commercially Insured Patients
              • Patient Share for PsA Drugs Among Commercially Insured Patients
              • Patient Share for PsA Biologics/Targeted Synthetic Agents Among Commercially Insured Patients
              • Patient Share for TNF-α Inhibitors Among Commercially Insured PsA Patients
              • Treatment Decision Drivers
              • Factors Affecting Choice of Biologics/Synthetic Targeted Agents for RA and PsA
            • Prescriber Preference
              • Prescriber Preferences for RA and PsA
              • Most Preferred PsA Therapies Absent Obstacles from Commercial Insurers
              • Rheumatologists' Predicted Prescribing Changes for RA in an ISP Scenario
              • Rheumatologists' Predicted Prescribing Changes for PsA in an ISP Scenario
            • Impact of Restrictions on Prescribing
              • Payer Policy Impact on Prescribing - Key Findings
              • Payer Restrictions Limiting Prescribing of RA Drugs
              • Payer Restrictions Limiting Prescribing of PsA Drugs
            • Indication-Specific Pricing: Physicians
              • Key Findings
              • Physician Perception of the Indication-Based Value of Autoimmune Drugs
              • Physician Receptivity to an ISP Approach
          • Market Access Landscape for Emerging Therapies
            • Impact of Emerging Therapies on Prescribing
              • Likely Impact of Emerging Therapies for RA and PsA
              • Rheumatologists' Likelihood of Prescribing Kevzara to RA Patients
              • Kevzara Prescribing Potential by Line of Therapy and Formulary Positioning
              • Patient Share Impact on TNF-α Inhibitors If Simponi Aria (IV) Is Approved for PsA
              • Patient Share Impact of New Therapies for PsA by Formulary Scenario
            • Payer Treatment of New Therapy Approvals in PsA
              • Payer Treatment of New Therapy Approvals for PsA
              • MCOs' Choice for Most Promising Emerging Therapy for PsA
              • Future Potential for ISP Amid New Therapy Approvals for RA and PsA
              • MCOs' Predicted Requirements for Additional Rebates on Newly Approved PsA Therapies
            • Prescriber and MCO Priorities for Emerging Therapy Evaluation
              • Key Findings
              • Most Important Attributes For Emerging RA and PsA Therapies: Rheumatologists
              • Most Important Attributes for Emerging RA and PsA Therapies: MCOs
              • Preferred Comparators for Emerging RA and PsA Therapies
          • Methodology
            • Primary Market Research Methodology: Physicians
              • Average Number of RA and PsA Patients Under Management
              • Insurance Coverage for RA and PsA Patients
              • Average Number of Years Practiced Post-Residency
              • Distribution of Medical Practice by Region
              • Surveyed Rheumatologists' Practice Setting
            • Primary Market Research Methodology: MCOs
              • Percentage of MCO PDs vs. MCO MDs
              • Plan Types Offered by Surveyed MCOs
              • Operations of MCOs: National, Regional, or Single State
              • Distribution of MCOs by Number of Covered Lives
              • Average Number of Lives Managed by Surveyed MCOs
              • Distribution of MCOs by Region
              • MCO Formulary Structure
              • Percentage of MCOs Marketing Self-Insured Plans
          • Appendix
            • Physician Survey
              • Physician-Reported Most Limiting PA Requirements on RA Drugs
              • Physician-Reported Most Limiting PA Requirements for PsA Drugs
              • RA Drugs Prescribed by Surveyed Rheumatologists
              • PsA Drugs Prescribed by Surveyed Rheumatologists
              • Physician-Reported Best Performing RA Drugs on Clinical Factors
              • Physician-Reported Best Performing PsA Drugs on Clinical Factors
              • Physician Use of Electronic Medical Records or E-Prescribing Solutions
              • Frequency of Prescription Changes Due To Electronic Formulary Checks
              • Reasons Why Physicians Would Not Welcome an ISP Approach
              • Level of ISP Knowledge and Research Among Surveyed Rheumatologists
              • Rheumatologists' Encounters with ISP for RA Patients
              • Impacts of an ISP Program on Physician Prescribing Behavior
              • Reasons Why Rheumatologists Would Not Prescribe Kevzara
              • Earliest Treatment Line in Which New PsA Therapies Would Be Prescribed
              • Methods by Which a Practice Determines Drug Value by Indication
              • Physicians' Expectations for Use of Real-World Evidence
            • MCO Survey
              • Control of MCO Formulary Development and Contracting
              • MCO Use of Standard Vs. Custom PBM Formularies
              • Degree of Customization of PBM Formularies
              • MCO Restrictions on RA and PsA Drugs in Commercial Plans
              • Trial-and-Failure Requirements for RA Drugs
              • Trial-and-Failure Requirements for PsA Drugs
              • MCO Level of Knowledge and Active Research in ISP
              • ISP Application by MCO Plan Type
              • ISP Application by Plan Type Among MCOs with ISP in Place or That Are Planning to Implement ISP in 12 Months
              • ISP Potential for Subpopulations and Lines of Treatment
              • Average Number of Months to Launch ISP Programs
              • Rebates in ISP Programs
              • Rebates in ISP Programs: Current and Near-Term Adopters
              • Sources of ISP Value Determination: Current and Near-Term Adopters Combined
              • Disease States Subject to Current ISP Programs
              • Stage of ISP Implementation by Future Adopters
              • Disease States Targeted by MCOs Adopting ISP Programs in 12 Months
              • Autoimmune Conditions Currently Subject to ISP Programs
              • Autoimmune Conditions Targeted by MCOs Adopting ISP Programs in 12 Months
              • Sources of Current ISP Programs for Autoimmune Conditions
              • Sources of ISP Programs for Autoimmune Conditions Used by MCOs Planning ISP in 12 Months
              • Methods of Tracking Drug Use by Indication
              • Preferential Tiering of RA and PsA Drugs by Current ISP Adopters
              • Rebates in ISP Programs: Future Adopters
              • Membership Threshold for Future ISP Adoption
              • Disease States Subject to Future ISP Programs
              • Autoimmune Conditions Targeted by MCOs Adopting ISP in 1 to 5 Years
              • MCO Analysis of Real-World Evidence for ISP
              • Methods of Tracking Use by Indication: Future Adopters
              • Reasons Why MCOs Will Not Employ ISP
              • Most Important Sources of ISP Value Determination: Future and Non-Adopters
              • Use of Cost-Effectiveness Models
              • MCO Selection of Best Performing Drugs by Autoimmune Indication
              • Status of Formulary Review for Kevzara for RA
              • Coverage Status of Kevzara on Commercial Plan Formularies
              • MCO Reaction to ICER Findings on RA Drugs
              • Reasons for Not Pursuing Additional Rebates in ISP
              • Coverage Status of Taltz and Siliq on Commercial Plan Formularies

        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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