Our leading subject matter experts share their insightful analysis and points of view to help you stay abreast of industry trends
Welcome back to our Market Access 101 blog series, which began with the basics of market access and covered how to improve formulary placement and secure coverage under the medical benefit. In this post, we’ll dive deeper into the medical benefit, explaining how payer/PBM contracting works—and why it’s increasingly necessary.
Essentially, all pharma companies want to know which of their competitors is contracting, but nobody wants to be the first to take the plunge. After all, once manufacturers begin payer/PBM contracting…
While the Inflation Reduction Act (IRA) may best be known for mandating Medicare drug price negotiation, the act did much more than that. Among its other accomplishments are the elimination of cost sharing for vaccines under Medicare Part D, as well as improved access to adult vaccines for Medicaid and Children’s Health Insurance Program (CHIP) enrollees.
Many vaccines target communicable conditions, and low use of these agents contributes to the diseases’ spread. When people are not vaccinated, they are at higher…
This article was originally published in Drug Channels.
In recent years, the rising cost of specialty pharmaceuticals has motivated payers to implement tighter restrictions and seek both traditional and value-based contracts with manufacturers. As manufacturers are already contracting with GPOs, distribution networks and medical practices, most would prefer to avoid contracting with payers and PBMs for their medical benefit products.
However, given the widespread adoption of medical benefit contracting, this trend is unlikely to lose momentum. Manufacturers must evaluate their current…
In 2021, Novo Nordisk’s Wegovy (semaglutide) gained FDA approval for chronic weight management in overweight or obese adults, hitting the market in June 2022 at a list price of $1,349 per 28-day supply. In clinical trials, patients achieved an astounding mean weight loss of nearly 15% after 68 weeks of treatment with Wegovy.
Excess body weight is a real problem in this country, as more than two-thirds of American adults are either overweight or have obesity. Despite efforts to diet and…
The past few years have seen an increase in the number of long-acting injectable (LAI) therapies for a variety of disorders and diseases, including schizophrenia, bipolar disorder, and HIV. These LAI antipsychotics and antiretroviral therapies include brand-name drugs such as Invega Sustenna (paliperidone palmitate by Jannsen), Abilify Maintena (aripirazole by Otsuka), and Cabenuva (cabotegravir/rilpirivine by ViiV).
Manufacturers with LAIs in the pipeline will need to be mindful about the persistent barriers to access faced by drugs with this formulation. Manufacturers with…
The Inflation Reduction Act (IRA), signed into law in August 2022, was intended in part to lower healthcare costs for families and small businesses. The IRA contains several provisions aimed at prescription drug costs which will roll out over the next few years, with the earliest taking effect this year. As of 2023, CMS will require pharmaceutical manufacturers to pay rebates to Medicare if their drugs’ prices increase at a rate which outpaces inflation.
The steady increase of drug prices has…
This article was originally published in Fierce Healthcare.
By the end of 2023, more than half of the total Medicare population is expected to be enrolled in Medicare Advantage (MA), which has climbed from 25.2 million members in 2020 to 31.5 million members today. Patients already have a surfeit of MA options, with the average beneficiary able to comparison shop between 43 MA plans.
To remain competitive in this high-growth environment, MA plans need an objective, normalized view of shifting market dynamics. With potential…
Welcome back to MMIT’s Market Access 101 blog series. Our first post, Understanding the Basics, covered the difference between the pharmacy and medical benefit structure, while our second, Improving Your Drug’s Formulary Placement, discussed how to overcome access barriers.
In this post, we’ll discuss what manufacturers should know about drugs covered under the medical benefit. We’ll cover pre-certification requirements, components of a medical policy, and distribution methods, and address the importance of aligning clinical pathways and policies to smooth patient access.
Following a severe season of respiratory syncytial virus, or RSV, in the U.S., multiple companies have reported that they have promising vaccine candidates for various patient populations in the late-stage clinical trial pipeline. The FDA could approve some of them as early as this year, for what is estimated to be a market worth more than $10 billion.
But just because the agency approves these vaccines doesn’t mean that many people will immediately have access to them. The process of gaining…
Payers’ use of copay adjustment programs has exploded over the past few years, and interest in them remains high. In addition, payers are now looking to bring down their drug spend by adopting newer strategies offered by companies with alternate funding programs. While many manufacturers are pushing back against these copay adjustment and specialty carve-out programs, patients remain caught in the middle.
Detrimental Impact on Patients Normally, when a manufacturer provides copay assistance for a drug, that dollar amount of that…
