MMIT Reality Check on Multiple Sclerosis (Oct 2021)

Payer Coverage:

A review of market access for multiple sclerosis treatments shows that under the pharmacy benefit, about 60% of the lives under commercial formularies are covered with utilization management restrictions. Around 43% of the lives under Medicare Part D formularies are not covered for at least one of the drugs.

Under the medical benefit, about 44% of the lives under commercial policies are covered with utilization management restrictions. Almost 71% of the lives under Medicare Part B policies have access to at least one of the drugs without utilization management restrictions.

For about 75% of the covered lives, payer pharmacy benefit formularies do not require step therapy (ST). Of the lives that require ST, 31% require multiple steps. Around 70% of payer-controlled pharmacy benefit covered lives require prior authorization, with 17% of those lives covered by policies that are restrictive as compared with a product’s FDA-approved label.

Trends:

FDA Approves Ponvory

In March 2021, the FDA approved the Janssen Pharmaceutical Companies of Johnson & Johnson’s Ponvory (ponesimod) to treat adults with relapsing forms of multiple sclerosis (MS), including clinically isolated syndrome, relapsing-remitting disease and active secondary progressive disease. The company says the drug’s price will be similar to those of other comparable treatments.

Most Payers Plan to Manage New Drug to Label

Although there are more than 20 FDA-approved disease-modifying therapies for multiple sclerosis, companies continue to bring new products to market. Zitter Insights found that the majority of payers expect to manage the newest entrant, the Janssen Pharmaceutical Companies of Johnson & Johnson’s Ponvory (ponesimod), to label. Almost two-thirds of the neurologists polled by Zitter Insights said they expect to prescribe Ponvory over certain MS therapies.

Prime: MS Spend Was Steady

More than 20 multiple sclerosis disease-modifying drugs currently are available in the U.S. But even with all the competition, prices for most of the agents are around $80,000 per year. Following updated professional treatment guidelines and the FDA approval of new therapies, including generics, Prime Therapeutics LLC conducted a study to determine spend and use of the agents over a two-year period. Spending for the class remained fairly steady, as generic use helped offset some costs.

Key Findings:

Market Events Drive Changes

In March 2021, the FDA approved the Janssen Pharmaceutical Companies of Johnson & Johnson’s Ponvory (ponesimod) to treat adults with relapsing forms of multiple sclerosis (MS), including clinically isolated syndrome, relapsing-remitting disease and active secondary progressive disease. In December 2020, the agency approved a new dosing time for Roche Group unit Genentech USA, Inc.’s Ocrevus (ocrelizumab) to treat adults with relapsing forms of MS, including clinically isolated syndrome, relapsing-remitting disease and active secondary progressive disease, as well as primary progressive MS.

Competitive Market Landscape

Contracting is prevalent among the interferons, where formulary preference drives choice. The orals are all different molecules. Contracting is expected to occur for these drugs but not to compete against the other brands. Competitive contracting on all the monoclonal antibodies (MABs) is also expected.

Pharmacy Benefit Implications

Interferons and Teva Pharmaceutical Industries Ltd.’s Copaxone (glatiramer acetate), as well as its generics, are considered first line in the treatment pathway. There are no true generics for the interferons. But with Copaxone generics, including Novartis AG division Sandoz Inc.’s Glatopa, available, some plans require those to be used. Interferons, Copaxones and orals are generally covered under the pharmacy benefit, although some coverage is seen for interferons under the medical benefit. MABs can be covered under both benefits, while infusible MABs appear most often on the medical benefit policies. All drugs for this indication are considered specialty drugs.

Key Players in Market:

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AIS Health Staff

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