Multiple Sclerosis: Payer Insight

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Publication Date:
July 2016
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Latest Update

Topics covered in this update include: payers’ approaches to the reimbursement of Ocrevus (ocrelizumab; Roche/Biogen) for relapsing remitting multiple sclerosis (RRMS) and primary progressive multiple sclerosis (PPMS); the impact of the launch delay of generic Copaxone 40mg/ml and potential steps that Teva could take to retain market share of its branded Copaxone; approaches to reimbursing Alkermes’ ALKS 8700 and opinions on ways by which Biogen could retain market share of Tecfidera.

*Latest* Update 3: April 2017
Update 2: January 2017
Update 1: October 2016
Original Publication: July 2016
Purchase of this report includes all updates*

This update tackles these key questions

  • How do payers react to the recent approval of ocrelizumab?
  • How is ocrelizumab likely to be covered in the US?
  • How do US payers feel about ocrelizumab’s competitive pricing? Are there any apprehensions?
  • How do payers react to the delay in launch of generic Copaxone 40mg/ml?
  • According to payers, what can Teva do to retain its market share of branded Copaxone 40mg/ml?
  • According to payers, what can Biogen do to retain market share of Tecfidera?

Update 2

This edition presents payer views on recent developments in the multiple sclerosis (MS) market. Topics include; cost-containment strategies for Zinbryta (daclizumab; AbbVie/Biogen) for the treatment of relapsing forms of multiple sclerosis (RMS); Teva’s chances of retaining market share of its branded Copaxone 40mg/mL; the future impact of generic fingolimod on the uptake of newer sphingosine modulator drugs for the treatment of multiple sclerosis (MS); as well as the recently proposed ‘budget impact test’ and how it may affect the uptake of new MS drugs in the UK.

Update 1

In this update, payers discuss reimbursement strategies for Zinbryta (daclizumab) for the treatment of relapsing forms of multiple sclerosis (RMS); provide opinion on cladribine as a potential treatment for RRMS; review the potential of ocrelizumab as a potential therapy for RRMS and PPMS ; and discuss coverage of siponimod as a potential treatment for secondary progressive multiple sclerosis (SPMS).

Drug prices rising while needs remain unmet. Now payers are fighting back

Payers have had it with the high cost of Multiple Sclerosis (MS) drugs and now they’re fighting back—demanding better data to justify pricing, and using a host of strategies to offset and contain costs. Get the details in Payer Insight: Multiple Sclerosis. You’ll learn what drives treatment costs up, what payers are doing to bring them down, why assessing cost effectiveness for MS drugs is so difficult, and how payers make access and reimbursement decisions.

We interviewed 12 US and EU payers with expertise in formulary development and drug reimbursement to get their perspective on the challenges facing the MS market. Plus you’ll find out how payers view pipeline MS treatments, what advice they have for Pharma, and which clinical trials to watch.

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“…it is not the insurance companies that are causing those co-pays to increase. It is the doing of the pharmaceutical industry.”
- Pharmacy Director, Pharmacy Benefit Manager

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Top takeaways

  • Ripple effect: Rising drug costs put pressure on other needed treatments for MS patients. Do payers envision a time when patients may have to go without?
  • Cost-effectiveness difficult to assess: What information are payers missing in order to measure cost-effectiveness? How will it influence PR and MA decisions?
  • Route of administration: The way drugs are administered has important consequences that affect cost and adherence, and shape payers’ decisions.
  • What about biosimilars and generics? Will they displace branded MS treatments, or are payers simply using them as a negotiating tool? Learn what will determine their near-term prospects.
  • Needs remain unmet: Current disease modifying agents only do so much. Payers point to four main areas of unmet clinical need that affect the MS pricing landscape in different ways.

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A payers’ eye view 

  • Cost containment: Payers are experimenting with a number of discounting, contracting, and payment schemes to contain drug costs. Which ones are showing the most promise?
  • Complex PR and MA decisions: Payers predict several factors will affect pricing, reimbursement, and market access decisions in the near term. Which ones will have the greatest impact?
  • Poor adherence: Patient adherence is key to assessing efficacy, but difficult to achieve. How does adherence affect drug choice, and what are payers doing to understand and improve it?
  • Lack of data: With little efficacy data to support MS drugs’ high prices, payers are pushing back. What data are they demanding? How will it affect future drug launches and access decisions?
  • Drugs Summary: Get a breakdown of approved and pipeline drugs, as well as payers’ thoughts about several oral, subcutaneous, and infusion therapies.
  • Coverage and access recap: Learn how coverage and access decisions are made in the US and several EU countries, and what payers are doing to improve transparency. Includes an update on Obamacare for US readers.
  • Clinical trials to watch: A comprehensive list of important upcoming trials for approved and pipeline products gives you a window into how the treatment landscape may evolve.
  • Warnings for pharma: Payers identify the two key things providers have to do if they want to avoid past mistakes.

Payers interviewed 

We interviewed 6 US payers and 6 from the EU. All interviewees have expertise in formulary development and drug reimbursement. All respondents requested that their details remain confidential.

US Payers

  • Pharmacy Director, Pharmacy Benefit Manager
  • Chief Medical Officer, Managed Care Organisation
  • Chief Medical Officer, PMT Chair, Managed Care Organisation
  • Pharmacy Director, Community Health Plan
  • Medical Director, Managed Care Organisation
  • Pharmacy Director, Health Maintenance Organisation

EU Payers 

  • Regional Pharmaceutical and Formulary Advisor, UK
  • Chief Hospital Pharmacist, Vice President Formulary Drug Committee, France
  • Pharmacist Director, France
  • Head of Drug Reimbursement, Germany
  • Member of the Drug Commission, Germany Medical Association, Germany
  • Chief Pharmacist, UK

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