Our leading subject matter experts share their insightful analysis and points of view to help you stay abreast of industry trends
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…
Across indications, biosimilar uptake is rapidly accelerating, with the number of biologics facing biosimilar competition more than doubling by 2026. This year’s impending launch of adalimumab biosimilars will serve as a case study for manufacturers, who will be studying the market’s response. Humira biosimilars have great potential to disrupt immunology market baskets, especially if multiple competitors employ aggressive discounting strategies.
To prepare for the impact of increased biosimilar competition in immunology indications in 2023, it is important to understand not only…
Welcome back to MMIT’s Market Access 101 series, in which we unpack the complexities of market access via a series of blog posts. In our first post, Understanding the Basics, we covered the difference between the pharmacy and medical benefit structure, the typical timeline for drug review, and why it’s critical to determine which entity makes formulary and coverage decisions.
In this post, we’ll address how to research and articulate your drug’s value proposition, how to overcome access barriers like prior…
This article was originally published in Drug Channels.
Given the growth of specialty pharmaceuticals, manufacturers will need to develop more aggressive contracting strategies to secure optimal market access for their medical benefit drugs. Shifting market dynamics, driven in part by the influx of lower cost biosimilars on the pharmacy benefit, will require pharma companies to focus more on rebating and cost minimization.
Understanding Market Forces Under the tiered design of a PBM, drugs covered under the medical benefit are directly impacted…
Many manufacturers are interested in which factors can give them an edge on obtaining preferred coverage with payers. This is especially true given the increasing competition in saturated categories such as immunology, diabetes care and breast cancer.
We scoured recent MMIT research to gain a better grasp on the factors that are top of mind for payers—those that will truly move the needle in terms of coverage determination. Our findings show that payers consider three main factors when evaluating therapies:
Cost…
For many pharmaceutical companies, planning for commercialization only begins in earnest when a drug has been submitted for FDA approval—which is far too late. Ideally, a company’s commercial and market access teams should be fully functional long before the approval stage, as many decisions must be made in the early phases of the drug development life cycle.
According to Deloitte, the average cost of bringing a pharmaceutical asset to market is $2 billion, yet more than a third of all product…
As if medical billing and coding wasn’t challenging enough, 2023 brings a new layer of complexity: the establishment of unique HCPCS codes for generic drugs. Specifically, the new codes affect generics approved under the FDA’s 505(b)(2) new drug application (NDA) and biologics license application (BLA) pathways.
In its Q3 2022 HCPCS Coding Cycle documentation, CMS issued 36 new HCPCS Level II codes to identify these products, effective Jan. 1, 2023. The agency also declared its intention to review additional 505(b)(2) drugs…
