How Are Payers Responding to High-Cost Therapies on Their Exchange-Based Plans?
The Affordable Care Act (ACA) has expanded access to insurance coverage to millions and has reformed health insurance requirements to assure more-comprehensive coverage of behavioral health and prescription drugs. Government reports estimate that more than 8 million people have enrolled in a health plan offered on the health insurance exchange, including 5.8 million estimated to have made their first payments. In addition, as many as 8 million people have gained coverage through the expansion of Medicaid in 27 states and the District of Columbia, creating a new, lucrative sales channel for the pharmaceutical industry. These changes stand to affect reimbursement and prescribing of therapies treating MS, an indication that largely strikes younger individuals who do not qualify for Medicare, and are therefore recipients of commercial coverage, Medicaid, or are uninsured. Expanded coverage means that individuals who were previously uninsured or who had access to less-generous commercial plans can now obtain insurance via exchange-based plans or Medicaid. As a result, demand for MS therapies should increase. However, the desire by MCOs to limit adverse selection in their exchange-based plans may also limit access to some therapies that are not preferred by payers, affecting uptake. MS therapies used include Bayer HealthCare’s Betaseron (IFN-β-1b), Novartis’s Extavia (IFN-β-1b), Biogen Idec’s Avonex (IFN-β-1a, IM), Merck Serono/EMD Serono’s Rebif (IFN-β-1a, SC), Biogen Idec’s Plegridy (pegylated interferon-β-1a), Teva’s Copaxone (glatiramer acetate), Biogen Idec’s Tysabri (natalizumab), Novartis/Mitsubishi Tanabe Pharma’s Gilenya (fingolimod), Genzyme’s Aubagio (teriflunomide), and Biogen Idec’s Tecfidera (dimethyl fumarate).

Questions Answered in This Report:

  • The ACA is expanding healthcare coverage and creating more business for medical practices. How will the demand for MS therapies increase under the ACA? What do physicians anticipate will be the clinical and economic impact of healthcare reform on their practices. How do they anticipate their payer mix will change? How has the use of high deductibles affected prescribing?

  • The reimbursement and prescribing of therapies treating MS is different in exchange-based plans than in traditional commercial plans. How do exchange-based plans’ drug formularies differ from those of commercial plans and Medicaid plans? Will they be open or closed? How much more restrictive will they be? How different will utilization restrictions be in Medicaid and exchange-based plans compared with traditional commercial plans? How have physicians prescribed MS therapies for their patients covered by exchange-based plans and how does it differ from their commercially insured patients?

  • Individuals covered in exchange-based plans may have different needs than those in the commercial plan population. What percentage of physicians and payers view individuals covered by exchanges to be distinct from those covered by traditional commercial plans? What are those differences? What do those differences mean for the pharmaceutical industry?


In this report, we explore the current and projected use of key established MS therapies in the expanding U.S. population of patients insured by Medicaid and commercial plans to be accessed through healthcare exchanges. In a survey of 100 neurologists and 40 MCO pharmacy and medical directors, we also gauge the market for MS therapies in this new sales channel. By evaluating the attitudes and expectations of prescribers and payers, stakeholders can gain an understanding of the strategies needed to navigate an historic expansion of the U.S. healthcare market.

Markets covered: United States.

Primary research: Online survey of 100 neurologists, and 40 MCO pharmacy and medical directors.

Epidemiology: The following populations with behavioral health disorders are represented: multiple sclerosis.

Population segments: None.

Author(s): Paula Wade

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