Severe asthma is a high-cost category with an increasing number of therapies that treat the condition. To help stakeholders absorb datapoints and perceptions from all directions and synthesize those insights into a tangible strategy for severe asthma, Zitter Insights surveys a leading panel of pharmacy and therapeutics (P&T) decision makers at payers and integrated delivery networks. The Managed Care Biologics and Injectables Index combines deep payer insights with the industry standard in market access information to produce quarterly reports and insights summaries on leading specialty brands.
More than 25 million people in the United States suffer from asthma, and about 5% to 10% of those suffer from severe allergic or eosinophilic asthma. While asthma overall has a societal cost of around $56 billion, those patients account for almost 50% of all asthma costs. The FDA has approved five biologics for this condition: Teva Pharmaceutical Industries Ltd.’s Cinqair (reslizumab), Sanofi and Regeneron Pharmaceuticals, Inc.’s Dupixent (dupilumab), AstraZeneca’s Fasenra (benralizumab), GlaxoSmithKline plc’s Nucala (mepolizumab) and Xolair (omalizumab) from Genentech, Inc., a member of the Roche Group, and Novartis Pharmaceuticals Corp.
Commercial payers with two-thirds of covered lives say that manufacturers’ ability to demonstrate efficiencies in drug costs is the most important factor in their decision making within the therapeutic class (see chart). Payers covering more than half of commercial lives say that a drug’s approval across numerous indications also is important, as is manufacturers’ ability to show efficiencies in overall patient treatment costs.
The Institute for Clinical and Economic Review’s (ICER) 2018 final report on asthma concludes that all five drugs “exceed commonly accepted thresholds for cost-effectiveness,” and none of the biologics met ICER’s threshold of $150,000/quality-adjusted life year. Commercial payers covering less than one-quarter of lives and payers covering half of Medicare lives say they used that report to decide upon tier placement for the therapies (see chart). Almost half of pulmo-nologists say that ICER findings have some impact on their prescribing behavior.
Among commercial payers and pulmonologists, efficacy and safety rank as the most influential drug characteristics for preferring a severe asthma agent. Other characteristics that commercial payers cited were the potential for contracting across multiple indications, dosing frequency and the potential for portfolio contracting or discounts. Medicare payers reported similar data. Pulmonologists also listed tolerability, route of administration and ease of use as important qualities.
The most recent biologic to gain FDA approval for severe asthma is Dupixent, which received that indication in October 2018. Payers with almost one-third of covered lives are likely to manage that therapy at parity with select severe asthma drugs. Payers covering more than three-quarters of lives say they will neither incentivize physicians to prescribe Dupixent to new starts nor incentivize providers to shift patients already on a severe asthma biologic to Dupixent.
Message: “The FDA has given breakthrough therapy designation to AstraZeneca and Amgen Inc.’s pipeline drug tezepelumab in patients with severe asthma without an eosinophilic phenotype based on the Phase IIb PATHWAY data. If the drug is approved, AstraZeneca will have therapies to cover eosinophilic and non-eosinophilic severe asthma, and payers may be willing to accept a portfolio contract from the manufacturer.”
Payer Thoughts: “We avoid portfolio contracts unless their rates are far superior. They inhibit competition in the class, which is a poor long-term strategy.”
Studies Show High Costs With Asthma Biologics
Prime Therapeutics LLC recently released the results of a study on the costs of severe asthma treatments. The condition has seen new therapies recently, and the treatments may be candidates for value-based contracts. Global Initiative for Asthma 2019 guidelines recommend a biologic for people with severe asthma, and the Prime study examined the use of five biologics.
ICER: Asthma Biologics Need 50% Price Cut
Two PBMs’ pharmacy chiefs tell AIS Health they agree with a new report by the Institute for Clinical and Economic Review (ICER), which finds that several biologic medications to treat uncontrolled moderate to severe asthma may modestly reduce disease exacerbations and improve quality of life. But the analysis also concludes that because the drugs are costly, the entire therapy class would need price discounts of at least 50% to be considered cost-effective.