U.S. Physician and Payer Forum

July 2013

Market Access for High-Cost Biologics in Multiple Sclerosis, Oncology, and Rheumatoid Arthritis

Introduction:

With the manifestation of the small-molecule brand patent cliff, specialty pharmacy drug spend, including high cost biologics, represents an increasingly large part of the pharmacy budget.  Furthermore, specialty drug costs continue to rise at rates in excess of 15% annually, and substantial product innovation in specialty categories will likely contribute to sustained levels of spending as similarly high-priced pipeline products receive approval.  As a result, pharmacy benefit managers and plan sponsors are focusing their attention and management acumen on the specialty market. 

Companies with an interest in this report include any company with a multiple sclerosis (MS), oncology, and rheumatoid arthritis (RA) agent on the market or in development, with a particular focus on those with biologics and/or current or emerging oral agents. Additionally, companies with strong portfolios in other specialty categories may be interested in considering market analogue scenarios.

This report will explore perceptions of the current and future state of the market for specialty pharmaceuticals in the MS, oncology, and RA, therapy areas. These categories represent some of the highest per-member-per-year specialty spending, and all have a substantial number of R&D candidates that will reshape the landscape in coming years, particularly given that these R&D candidates represent traditional injectable or infusible biological specialty products as well as oral formulations, biosimilars, and companion diagnostics.   In the context of the current and expected market environment, this report will evaluate the evolution of product access and utilization strategies and managed care specialty pharmacy management approaches.

Insights provided in this report will be derived from an analysis of survey responses from 149 prescribers (neurologists, oncologists, and rheumatologists) and 41 pharmacy and medical directors at managed care organizations (MCOs). By understanding how product innovation and experimentation in management of specialty pharmaceutical products will shape the market for specialty products in market-leading therapeutic classes, drug developers may begin to identify areas on which to focus in order to maximize opportunity and mitigate risk. This report will also provide insight on how the therapeutic areas of MS, oncology, and RA may serve as an experimentation proving ground indicative of models that will be followed in specialty pharmacy management and utilization across other categories.

Questions Answered in This Report:

  *   Emerging stakeholders and evolution of intermediaries:
- Advent of both internal and external specialists in reimbursement issues.
- Development of accountable care organizations and their ability to influence access and utilization of specialty pharmaceutical products.
- Perceptions of the function of specialty pharmacy providers and specialty distributors, and their role and relationship in the value chain.

  *   Experimentation in managed care management strategies:
- Application of traditional management tools such as prior authorization, step therapy/sequencing requirements, and differential cost-sharing requirements to specialty categories.
- Introduction of new reimbursement models that seek to align incentives and prioritize patient outcomes and value: pathway-aligned financial incentives, the move of some medical benefit speciality drugs to the pharmacy benefit for more control, shifts in reimbursement models for physician-administered products.

Scope:

This U.S. Physician & Payer Forum reveals physicians’ and payers’ insights into prescribing and reimbursement decisions for high-cost biologics in the United States. This report will provide results from a survey designed to explore how access to high-cost biologics is being shaped by payer-led strategies and other industry issues that include sequestration, clinical pathways, and drug delivery methods. Through an examination of specialty drugs across multiple indications, this report provides insight into how payers and physicians compare in their use, opinions of, and responses to trends regarding specialty drugs in their respective indications.

Markets covered: United States.

Primary research: Online survey of 50 oncologists, 49 neurologists, 50 rheumatologists, and 41 MCO pharmacy or medical directors.


Search Reports

Mentioned in this report:

  • MS:
  • - Teva
  • - Biogen Idec
  • - Sanofi
  • - Novartis
  • - Merck
  • - Bayer HealthCare
  • - Abbott/AbbVie
  • - GlaxoSmithKline
  • Oncology:
  • - Roche
  • - Novartis
  • - Amgen
  • - Celgene
  • - Sanofi
  • - BMS
  • - Bayer HealthCare
  • - Takeda
  • RA:
  • - Abbott/AbbVie
  • - Pfizer
  • - Amgen
  • - Johnson & Johnson
  • - Pfizer
  • - Merck
  • - AstraZeneca
Decision Resources Group brands include: