{"id":774799,"date":"2022-04-27T07:40:40","date_gmt":"2022-04-27T07:40:40","guid":{"rendered":"https:\/\/www.pm360online.com\/?p=774799"},"modified":"2022-04-27T14:19:05","modified_gmt":"2022-04-27T14:19:05","slug":"roadmap-to-improved-coverage-and-access-for-specialty-products","status":"publish","type":"post","link":"https:\/\/www.pm360online.com\/roadmap-to-improved-coverage-and-access-for-specialty-products\/","title":{"rendered":"Roadmap to Improved Coverage and Access for Specialty Products"},"content":{"rendered":"

As specialty pharmaceutical products are becoming increasingly complex due to more technology-driven drug development, the path to payer coverage is complicated by the need to understand emerging therapeutics, unique delivery systems, and personalized patient support programs. For pharma marketers to achieve success across markets, they must adapt strategies to various payer channels. But any roadmap to better coverage is not complete without ways to improve access. So, marketers must also learn to navigate administrative systems and develop practical solutions to assist providers and patients alike whether they are launching a new-to-market specialty product, a new indication, or defending their position in a competitive therapeutic area.<\/p>\n

A Shifting Landscape<\/h3>\n

Payer vertical integration,\u00a0including acquisition of specialty pharmacies, has changed the landscape and underscores business implications of integrated decision-making.1<\/sup><\/p>\n

Insurers have gained control of downstream pharmacy and provider organizations, making it easier to implement integrated management approaches such as site of care and formulary management strategies (see Figure 1).2<\/sup><\/p>\n

\"\"<\/a>Coverage by Market Segment<\/h3>\n

Commercial health plans and pharmacy benefit managers (PBMs) continue to manage specialty products through plan-sponsored tiered formularies, with patient cost-sharing differentials steering access to preferred products. Specialty cost sharing is often a percentage of the drug cost (i.e., 30% for the preferred specialty tier) with a higher percentage (i.e., 50%) collected for non-preferred products. Commonly seen in specialty pharmacy, high out-of-pocket (OOP) costs present a significant barrier to access for many patients.<\/p>\n

As mentioned in a recent RxBenefits blog, employers are looking for other ways to address the growing impact of specialty medications<\/a> on employer healthcare costs, including carve-out strategies from the pharmacy benefit.3<\/sup>\u00a0This approach can add administrative complexity and result in gaps in coverage if benefits are not managed properly. Health plans and PBMs instead are leveraging their vertical business relationships to develop integrated programs that address the needs of the \u201cwhole patient\u201d and bringing these solutions to self-insured employer group customers. Marketers should look beyond the product specialty at hand and consider engagement opportunities with primary care and behavioral health providers where appropriate.<\/p>\n

Increasingly, exclusionary formularies are expanding across market segments in therapeutic classes where sufficient competition exists to drive preferred contract pricing. Medicaid formularies are generally exclusionary since differential cost sharing is limited; and Medicare formularies likewise tend to be exclusionary, with a percentage cost share applied for covered specialty products. The unique structure of Medicare Part D impacts patient cost sharing over the course of the benefit year and is an important consideration for developing strategies to ensure patients have uninterrupted access to specialty drug treatment.<\/p>\n

Each formulary type (commercial, Medicaid, and Medicare) offers an appeals process allowing for exceptions based on medical necessity or prior failure of a covered drug. Helping prescribers and larger health system administrators navigate these various coverage and benefit policies is an important aspect of managed markets access strategy.<\/p>\n

Key Considerations for Improving Specialty Drug Coverage<\/h3>\n

If you are in need of strategies to help ensure more optimal coverage of your specialty product, then keep these six aspects in mind:<\/p>\n