MMIT Reality Check on Hemophilia A (Factor VIII) (Oct 2021)

Payer Coverage:

A review of market access for hemophilia A (factor VIII) treatments shows that under the pharmacy benefit, about 38% of the lives under commercial formularies are covered with utilization management restrictions. Around 20% of the lives under health exchange formularies are not covered for at least one of the drugs.

Under the medical benefit, about 58% of the lives under commercial policies are covered with utilization management restrictions. Almost 75% of the lives under Medicare Part B policies have access to at least one of the drugs without utilization management restrictions.

For about 83% of the covered lives, payer pharmacy benefit formularies do not require step therapy (ST). Of the lives that require ST, 8% require multiple steps. Around half of payer-controlled pharmacy benefit covered lives require prior authorization, with 43% of those lives covered by policies that are restrictive as compared with a product’s FDA-approved label.

Trends:

Genentech Hemophilia A Drug Displays Long-term Safety, Efficacy

A late-stage study of Roche Group member Genentech, Inc.’s Hemlibra (emicizumab-kxwh) reported no new cases of thrombotic microangiopathy or serious thrombotic events associated with the drug, which was approved by the FDA in 2018 to treat hemophilia A with or without factor VIII inhibitors. The study also showed that Hemlibra over the long-term follow-up effectively delivers bleeding control.

FDA Gives Additional Approval to Wilate

In October 2019, the FDA expanded the label of Wilate (von Willebrand factor/coagulation factor VIII complex [human]) to include the treatment of adults and adolescents with hemophilia A for routine prophylaxis to reduce the frequency of bleeding episodes and for on-demand treatment and control of bleeding episodes. The agency initially approved the Octapharma USA intravenous injection in 2009.

Employers Are Urged to Address Costs

Managing hemophilia treatment is a complex task, and the bleeding disorder, though rare, can be a major cost driver for employer-sponsored health plans. Yet employers can take immediate steps — from exploring site-of-care options to regularly gathering meaningful data — to better contain pharmaceutical costs that represent upwards of 90% of the total cost of care.

Key Findings:

Market Events Drive Changes

In October 2019, the FDA expanded the label of Octapharma USA’s Wilate (von Willebrand factor/coagulation factor VIII complex [human]) to include the treatment of adults and adolescents with hemophilia A for routine prophylaxis to reduce the frequency of bleeding episodes and for on-demand treatment and control of bleeding episodes. In February 2019, the FDA approved Novo Nordisk’s Esperoct (turoctocog alfa pegol) for use in children and adults with hemophilia A for routine prophylaxis to reduce the frequency of bleeding episodes, on-demand treatment of episodes and perioperative management of bleeding.

Competitive Market Landscape

The market is trending toward longer half-life recombinant products. Anticipated product approvals may develop improved product placement based on potential costs, adherence and efficacy advantages. The market will be managed more tightly as we start seeing an increase in longer acting products and gene therapy products in the pipeline. For the most part, hemophilia products are viewed as undifferentiated brands.

Pharmacy, Medical Benefit Implications

While there are very limited instances where products are not covered under either the medical and/or the pharmacy benefits, there is minimal management of specific products. More pharmacy coverage is seen as products are listed as self-administered specialty drugs. For managed Medicaid, few MCOs will carve out hemophilia products to the state Medicaid fee-for-service programs. Coverage is prevalent under Medicare Part B.

Key Players in Market:

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AIS Health Staff

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