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Perspectives on Medical Benefits and Restrictions

Posted by Matt Breese on Dec 13, 2016

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Just a decade ago, complex benefit policies and reimbursement restrictions were an afterthought for pharmaceutical manufacturers. Today, the pharmaceutical industry has established managed markets teams. These teams influence, understand and closely monitor both medical benefits and restrictions.

Payers, PBMs, and a multitude of other factors affect market access and coverage policies. Pharma companies can help reduce the barriers to prescribing by clearly communicating to clinicians the medical benefits and restrictions related to their products. Favorable medical benefit policies and contracting can help pharma companies edge out the competition. 

Market Access Challenges:

Market access is becoming increasingly critical for a product to be successful in the pharmaceutical industry. According to Philip Carrigan, representative director at Morunda Japan:

“Market Access teams need to be able to communicate the ‘value’ of their product to a range of customers who influence uptake, understand the current health resources for the relevant clinical condition, quantify the overall impact of a product intervention in terms of clinical outcomes, and identify resources required to manage the patient.”

The rising costs of specialty drugs make it increasingly challenging for healthcare organizations to ensure patients are receiving adequate treatments. For example, “Over 95% of patients diagnosed with any of the seven most prevalent cancers are subject to some form of control placing restrictions on access,” according to PM360. To manage high treatment costs, many payers pass financial burdens onto patients.

The Market Access Landscape for Antipsychotic Treatments:

Antipsychotic treatments are one example of specialty drugs that face limited market access. MMIT’s Reality Check on Antipsychotics revealed that Medicare plans do not cover antipsychotics for the greatest percentage of lives. In addition, health exchange formularies restrict access in the form of prior authorizations or step therapy policies for a significant amount of lives.

The graphic below illustrates how reimbursement restrictions affect market access for antipsychotic treatments. In fact, approximately 40% of prior authorizations are restrictive and 45% of step therapies require 2 or more product steps to qualify for coverage.

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MMIT Network helps pharma market access teams with specialty drugs and highly managed drug classes understand medical benefits and restrictions, identify contracting opportunities, and manage their messaging based on specific prescribing landscapes.


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Topics: Market Access