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Utilization Management

Finding Confidence In the
Utilization Management Tug of War
The Market Access landscape is shifting on a daily basis. How are you responding and adapting to these changes?

The Market Access landscape is shifting on a daily basis and there are too many factors at play at the national and local level. Payers and PBMs are focused on establishing control and ever changing policy adds to the uncertainty. Whatever realities that exist today might be gone tomorrow.

Mainly, it is important to gauge:

  • The hurdles that stand in the way of value-based agreements.
  • The role and impact of couponing.
  • The specific therapeutic areas were value-based contracts are most concentrated.
  • Where the best opportunities for strategic growth exist?

How are you tracking competitor couponing at a national and territory level?


Therapy, brand and geography are all at play when factoring couponing strategies. The realities of one state may differ from the next. When gauging financial risk and entering contract negotiations, it’s crucially important to understand the nuance that exists in local healthcare dynamics, how competitors are positioned in each market and to leverage this information as a way to gain better market share.

For example, the national risk in auto-immune is roughly 45% across the country. However, that risk is higher in Missouri, Texas, Hawaii and Georgia.

“Pharma may find it necessary to focus on contract strategies, such as rebates, to ensure better formulary placement and decrease the need/utilization of expensive copay assistance programs, but other strategies like debit cards or point of sale rebates may also be viable.”

Do you have the data you need to accurately project and measure the effectiveness of your contracts?


Claims data is an integral part of understanding where treatments are being prescribed and the potential barriers that might exist. Combined with lives data, a bounty of insights such as the percentage of a population become clear.

Projecting how contracts will play out and drive pull through hinges on your ability to get a complete view of where your brand – and your competitors – sit on formularies, as well as the control and influence over benefit utilization within each market. It’s also critical to understand the impact of any coupon programs and being able to quantify the risk and impact associated with those benefit designs.

Every market has unique and ever-changing risks and opportunities. Keeping pace with those dynamics can be an extremely daunting task, but our state- and plan-specific data and insights allow companies in the US healthcare space to do just that.

What insight do you have on shifting medical and pharmacy benefit coverage?


Understanding where to focus in your planning is critically important, particularly in areas such as specialty pharma where lack of visibility is a growing challenge.

What mix of data are you using to determine where treatments are reimbursed? A single source of truth for lives and claims data helps to clear a path, but industry insights and expertise can harness that data and offer predictive analysis of enrollment, benefit design and payer/provider influence over benefit utilization to uncover trends and actionable insights to keep moving forward.

Market Access is the cornerstone of success – From molecule to market maturity
From the data it takes to build evidence-based solutions, to critical insight on local markets, to personalized services that will inform or transform a brand’s commercial approach, DRG is the only strategic partner you need for US markets