What Does Member Disruption Mean to Payers?
Recently, payers have started to use the phrase “member disruption” to refer to the potential impact of an impending formulary change on their members. This qualitative term is mentioned with increasing frequency during contracting discussions and P&T sessions, although the weight of these considerations varies between organizations. Member disruption describes the impact of formulary changes […]
Spotlight on Vaccines: 2023’s RSV Immunization Approvals
Respiratory syncytial virus (RSV) can impact anyone, but infants and older adults are most at risk of illness. With multiple new immunizing agents gaining FDA approval in 2023—and more in the pipeline—manufacturers and payers have a role to play in educating patients and providers about the importance of immunizations to combat RSV. RSV, a contagious […]
What Pharma Wants to Know About the Medicare Drug Price Negotiation Program
Since the passing of the Inflation Reduction Act (IRA) last fall, pharma companies have been bracing for the impact of its provisions. The main healthcare-related IRA policies are the out-of-pocket spending cap, the Medicare Drug Price Negotiation Program, and the penalty for increasing drug prices faster than inflation. To get a better sense of what […]
Market Access 101: Formulary and Medical Exceptions
Beginning with the basics, our Market Access 101 blog series has addressed how manufacturers can improve formulary placement for pharmacy benefit drugs, secure coverage and assess the need for contracting for medical benefit therapies. In this final post, we’ll explore what it means to request a formulary exception or medical exception for a non-covered therapy. […]
How Real-World Data Helps Manufacturers See the Complete Market Access Story
This article was originally published in BioPharma Dive. Over the past few decades, pharma companies have perfected the art of using market access data to support product launches, negotiate payer discounts, and secure preferred status and positioning. Manufacturers typically track formulary and medical policy guidelines and restrictions—including prior authorization and step therapy requirements—for a product and its competitors, […]
Market Access 101: Key Factors in Medical Benefit Contracting
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 […]
Spotlight on Vaccines: The Inflation Reduction Act’s Impact on Coverage
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) […]
Weighing the Benefits: Are Payers Likely to Cover Weight Loss Drugs in 2023?
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 […]
Removing Access Barriers for Long-Acting Injectables
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 […]
Staying Competitive in an Expanding Medicare Advantage Market
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 […]