Pricing and Reimbursement in Neurology: Payer Views [2020]

Understanding payer challenges in Multiple Sclerosis, Epilepsy, Migraine and Neurodegenerative disease

Despite wide unmet need across a number of neurological conditions, no really high impact breakthrough therapies have come to the market in recent years. The price for generics has continued to rise—sometimes dramatically—and the broad upward trend in new drug pricing shows no sign of abating. Payers want effective therapies and evidence of utility, and many question the value of new drugs that offer only marginal clinical benefits. What are cost-conscious payers doing to manage the escalating cost of neurological disease treatments?

To examine approaches to pricing and reimbursement (P&R) in multiple sclerosis, epilepsy, migraine, Alzheimer's disease and Parkinson's disease, we interviewed leading US and European payers. In Pricing and Reimbursement in Neurology: Payer Views they examine how price trends are affecting patient access, the impact of COVID-19, and they reveal the strategies they employ for formulary placement, tiering, reimbursement and pricing.

Payers explore each condition:

Multiple sclerosis

• Do payers believe that Novartis' Mayzent pricing represents another step towards lower pricing for DMTs in general?
• How has the lower launch price of Roche's Ocrevus affected its uptake in terms of market share compared with other DMTs for multiple sclerosis?

Epilepsy

• How do payers view the pricing of newer epilepsy treatments such as UCB's Briviact and GW Research's Epidiolex/Epidyolex?
• What are payers' views on the huge price increases of phenytoin sodium capsules that prompted the case against Pfizer and Flynn Pharma for overcharging?

Migraine

• How do payers assess manufacturers' pricing strategies of GCRP inhibitors?
• How does Amgen/Novartis' Aimovig compare with other treatments in terms of P&R policy and how is that impacting payer behaviour?

Alzheimer's disease

• How likely is it that current drug prices will remain sustainable as the patient population increases?
• What impact does the current pricing of Alzheimer's disease drugs have on patient access?

Parkinson's disease

• With low-cost generics widely available for first-line treatment of Parkinson's disease, what are payers' opinions on the pricing of branded combination therapies, such as AbbVie's Duodopa/Duopa?
• What do payers have to say on the pricing of newer drugs such as Newron Pharmaceuticals' add-on therapy Xadago?

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What industry experts say...

"We've seen some patients switch over to Ocrevus. However, we're beginning to see more than its fair share of additional business, which makes us wonder, as a plan, if doctors are switching over to Ocrevus because they can get the revenue for those infusions. We have other drugs out there that are discounted. Even though the list price may be 20 percent more, they are rebated, which makes the price actually less, and the patient can take them themselves. And so we've talked at our P&T meeting about looking at this class and specifically if we have to pull in the reins a little bit on Ocrevus, because we're seeing some patients being moved around. Rheumatologists and neurologists have infusion centres as part of their practice, and I think that bringing patients back into the office for infusions is probably a bigger driver than the lower net price."
US Payer 4

"We have had three anti-epileptic drugs since 2011. None of these drugs got an added benefit which was a wrong decision by the G-BA. For a specialist paediatrician to treat epilepsy, they need some drugs to change, maybe even if it's officially a direct comparison, it's not superior. Nevertheless, for a single patient, it may be okay if one doctor were committing to another drug that is similar, but a little bit different. So you may have a chance to treat these patients. In my view, the big problem for our system is that these anti-epileptic drugs are not available in most cases, because epilepsy may be hard to treat and we may have to do a lot to control that. In my view the G-BA must accept newer drugs and mustn't say 'no improvement in outcome' for this drug because physicians need access to all existing drugs, to treat patients in the best way."
German Payer 2

"Pharma must define the unmet need and patient populations that are going to be addressed with this product. If you're going to come in and say, 'Hey, we're going to be there for every Parkinson's patient out there,' I would say, 'Well, no. I already have a lot of drugs out there for your typical Parkinson's.' But if you're saying, 'Hey, we're really going after those patients who are experiencing a certain amount of off-periods per day.' Or in MS, 'We're going after patients who have disability progression on one prior service.' Or in epilepsy where they're going after patients who are still having seizures even after they tried two different products. So I prefer to have that right up front; defining unmet need and specific patient populations that they may be trying to address."
US Payer 2

What to expect

A detailed report exploring payer views and attitudes to pricing and reimbursement of innovative and biosimilar/generic neurology therapies for multiple sclerosis, epilepsy, migraine and neurodegenerative diseases:

• An examination of 11 key issues that are impacting P&R decisions for neurological drugs
• 24 targeted questions to US and European payers
• Their responses which provided 55 insights supported by 79 directly quoted comments

Deliverables: Include PDF report and PowerPoint slide deck

Pricing and Reimbursement in Neurology: Evaluating Payer Strategies is delivered as:

• A detailed PDF report including all insights, quotes and intelligence exhibits
• A useful PowerPoint slide deck providing a summary of the report's key findings to include in your presentations or for sharing with colleagues

Payer contributors

Payers contributing to this report have been screened to ensure they:

• Have at least three years of experience as a drug-budget manager.
• Are directly responsible for P&R negotiations for neurology drugs, whether for a government body, hospital, pharmacy-benefit manager, insurance company, purchasing group or other payer
• Are a primary decision maker, key influencer or member on a P&R committee or a drug and therapeutics committee with direct involvement in reimbursement policy for neurology drugs

Payers interviewed included:

• David Levy has worked for the UK NHS for some 20 years and is currently the Regional Medical Director for the Midlands and the East. His previous roles include the Medical Director of United Lincolnshire Hospitals Trust, the President of the British Columbia Cancer Agency, an academic healthcare organisation, and posts with the Department of Health, York and Humber SHA and Sheffield Teaching Hospitals, the latter as a consultant neuro-oncologist, managing complex patients and their families.
• US Payer 1 is a Vice President of Clinical Strategy and Pharmacy and has held various executive leadership roles in specialty pharmacy. Experience includes oversight for pricing, industry and trade relations, client service, and service innovation, as well as additions of new services and performance measures.
• US Payer 2 is a Pharmacy Director for a regional payer that covers commercial and Medicare lives. He runs a Pharmacy and Therapeutics committee and is directly involved in formulary and coverage decisions for oncology products.
• US Payer 3 has worked as a pharmacy director for a pharmacy benefit manager and, consulted directly with managed care health plans. US Payer 3 has advised them on their formularies, clinical programmes and utilization management, with the aim of ensuring appropriate utilization and maximizing the use of generics to reduce the cost of pharmaceuticals, while focused on improving their members' health.
• US Payer 4 is a Pharmacy Director for a regional payer that covers commercial and Medicare/Medicaid.
• US Payer 5 is involved in the overall development of management strategy for a US payer, including formulary coverage, as well as utilization management and different trend management opportunities. Prior to that he was involved more on the client side, managing clients in terms of commercial exchange, Medicaid and Medicare programs.
• German Payer 1 is Head of Drug Reimbursement for a public healthcare corporation.
• German Payer 2 has been a member of a board of directors in Baden-Württemberg, with responsibilities for drugs, medical products and therapeutic appliances.

To ensure full and frank opinions were expressed we have agreed to keep the names of some contributors anonymous.

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