How Are Payers Reacting to Elevated Costs and How Will the Cost Trend Impact Specific Brands?
The nation’s healthcare payers are using multilayered cost and utilization control strategies to rein in the double-digit growth in their costs for biologics and other high-priced specialty therapies, with specialty drugs expected to consume half of the drug spend by 2018. Among the areas of greatest concern is the autoimmune disease category (especially rheumatoid arthritis [RA]), considered the highest-cost disease category in the U.S. (according to the pharmacy benefit management industry) and the one for which cost trend is expected to accelerate the most, next to oncology.

U.S. managed care organizations (MCOs) have adopted multiple cost-control strategies on every front: prescribing is addressed by prior authorization and step therapy protocols; utilization is affected by increased member cost sharing; and infusion costs are reined in by site-of-care restrictions. The use of specialty and mail-order pharmacies offers better control through tracking, reporting, and management of drugs.

A variety of therapy options exist for the treatment of the autoimmune conditions RA, psoriatic arthritis (PsA), and systemic lupus erythematosus (SLE). Typically in the case of RA and PsA, conventional disease-modifying antirheumatic drugs (DMARDs) are prescribed first, and the wide availability of generic products in the class helps hold down costs for payers and patients. For patients who do not respond to those treatments, the highly effective newer biologic versions of DMARDs, including the frequently prescribed tumor necrosis factor-alpha (TNF-α) inhibitors (i.e., Amgen/Pfizer’s Enbrel [etanercept], AbbVie’s Humira [adalimumab], and Janssen/Biotech’s Remicade [infliximab]), offer patients a chance to get relief and resume life’s activities. These and other later-line and emerging therapies—including some of the first biosimilars to come to the U.S. marketplace—will create more cost pressures for managed care companies but also will set the stage for competitive contracting and preferred drug tiering, a key strategy in holding down costs. For SLE, GlaxoSmithKline’s Benlysta (belimumab) is the first drug approved for SLE in more than 50 years and is the first biologic approved for the indication. However, uptake of Benlysta has been tempered by its relatively high price in a largely generic market coupled with physicians’ perception of its modest efficacy, slow onset of action, and inability to be used in patients with severe, life-threatening organ involvement.

Questions Answered in This Report:

  • Prescribing and tiering of autoimmune therapies. What percentage of patients treated for RA and PsA are prescribed a biologic agent, and what percentage of patients receive a DMARD? Which of the biologic treatments and the oral Janus-activated kinase (JAK) inhibitor Pfizer’s Xeljanz (tofacitinib) are more often prescribed as a first-line versus a second-line therapy for RA and other conditions? How are the various approved treatments and off-label products positioned in MCOs’ drug benefits in terms of coverage tiers, and which are more likely to be excluded from coverage now and in the next 12 months? Do Enbrel, Humira, and Remicade face any real competition when it comes to MCO coverage and physician prescribing? How do these factors also affect reimbursement and prescribing for SLE?

  • Cost-control strategies employed for high-cost biologics. What level of control from payers do rheumatologists encounter when prescribing biologic therapies and Xeljanz? Which of the cost-control measures are most likely to be encountered by specialists for each of the three conditions? How much of a concern for MCOs is the increased administration of biologic therapies at hospital-based sites of care, and what percentage of MCOs has enacted restrictions on the sites of care? What is the most common reimbursement method for infused and self-administered autoimmune products?

  • Impact of payer controls on prescribing. To what extent have payer tiering decisions and restrictions impacted rheumatologists’ prescribing of biologic therapies as well as Xeljanz for RA, PsA, and SLE? For which products do specialists report that they have decreased their prescribing rate because of payer controls? What is the result of payer controls on rheumatologists’ tendency to follow preferred drug lists? What is the extent of specialists’ use of specialty pharmacies? How do specialists react to site-of-care restrictions?


This U.S. Physician & Payer Forum report contains insights from a survey of 101 rheumatologists and 40 MCO pharmacy and medical directors (20 pharmacy directors and 20 medical directors) regarding the impact of high-cost biologics on the tiering and prescribing of autoimmune therapies for RA, PsA, and SLE. We explore the impacts on specific therapies treating these three conditions and implications for the pharmaceutical industry.

Markets covered: United States.

Primary research: Online survey of 101 rheumatologists and 40 MCO directors.

Author(s): Paula Wade