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Perspectives on Highly Managed Class Restrictions

Posted by Matt Breese on Oct 6, 2015

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As pharma continues developing, launching and promoting drugs, so must the entire healthcare environment adapt to accommodate the growing market baskets. Pharmaceutical manufacturers need to understand how payers will cover and how providers will prescribe these products. Utilization management strategies and general product restrictions have a tidal effect on the success of pharmaceutical brands.

An article from AJMC evaluates the basics of how payers are restricting access to PCSK9 drugs, like Repatha and Praluent. A huge portion of the US population is eligible for expensive, chronic medications. As such, payers must strike a crucial balance between creating restrictions that ensure plans can support treatment, yet allow patient access to life-changing treatments. Health plans and PBMs, like CVS health, are hoping that competition will help drive prices down for products like these through the manufacturer discounts.

In other therapeutic classes, like detoxification agents and anti-addiction treatments, restrictions are loosening their grip on the market. Historically, doctors required prior authorization for prescribing drugs in nearly every addiction case; however, policy has pivoted to increase patient access to vital addiction treatment by eliminating antiquated roadblocks.

Examining highly managed classes from a provider and pharmacist perspective reveals underlying drivers of how restricted treatment access translates to the point of care. For instance, a program called Meds to Beds, where medications are delivered to patients at their bedside prior to their discharge, provides valuable insight. In this environment, physicians and pharmacists work in close proximity to streamline communications and hurdle restrictions, like prior authorizations. Although tailored for specialty drugs administered in a clinical setting, this approach allows for low-friction information exchange between healthcare experts and patients to determine the best treatments based on real-time circumstances and drug availability.

An administrator of Oncology Pharmacy and Infusion Services provides some real-world examples of how difficult it can be to deliver the appropriate treatments due to insurance coverage concerns. She calls for payers to continue evolving coverage strategies according to new, evidence-based indications. When it comes to immune-oncology products, payers may require step therapy protocols, where drugs need to step through preferred agents. For newly launched agents in this market basket, reimbursement concerns pop up frequently and off-label use is often not included in coverage policies. With highly managed products like these, it is essential for administrators to have high familiarity with manufacturer programs, co-pay translations and patient assistance programs.

Getting back to basics, payers restrict patient access to specific medications in order to cut costs and short-term spending. Whether the costs falls on patients, health plans or manufacturers (via discounts), some entity must pay for expensive pharmaceuticals. The Harvard Business Review highlights the increasing prevalence of prior authorization, step therapy and quantity limits utilized for atypical antipsychotic meds in Medicaid programs. The article proposes the solution of a value-driven health care system which focuses more on the value of a treatment, rather than the cost and access of a drug.

While pharmaceutical manufacturers, payers and providers all have different takes on drug restrictions, it is clearly a topic that is front-of-mind for healthcare.  

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Topics: Specialty, Market Access