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Managed Markets Insights

Perspectives on Medical Therapy Access, Reimbursement and Payer Influences

Doctor Communication and Medication Adherence

A recent large-scale survey found that people living with rheumatoid arthritis (RA) believe that their relationship with their healthcare professional can positively impact the management of their disease.[i] But how does doctor-patient communications influence the patient’s adherence to medication protocols? Our December 2015 Abandonment …

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Hassle Factor-How Do Therapeutic Areas Differ?

The U.S. healthcare system incurs more than $200 billion in avoidable costs every year, and much of this staggering number is attributed to prescription abandonment and non-adherence to recommended drug therapies.1 Simply put, patients who do not fill their prescriptions cannot take the medications …

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The benefits of being the fly on the wall

Our pharmaceutical customers invest months — sometimes years — and massive resources in preparing a new drug or health technology for market launch.  Both those launching a product and those carefully watching a competitive launch have questions about how the product’s value proposition will …

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PCSK9 Inhibitors: A New Class of LDL-C Lowering Treatments

Since their development in the late 1980s, Statins have remained the gold standard in treating and regulating cholesterol production. Blockbuster drugs such as Lipitor (atorvastatin) and Crestor (rosuvastatin) produced annual revenues of over $12B globally in the mid-2000s. However, this blog post will discuss …

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Co-pay discount programs still in the cards

Despite the backlash amongst health plans and pharmacy benefit managers (PBMs) when co-pay cards first arrived on the managed markets scene, discount programs are still a frequently cited topic during payer visits, according to Zitter Health Insight’s ongoing research on value added programs. Co-pay …

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Trends in Psoriasis Payer Management

The psoriasis marketplace has grown significantly in the last couple of years with newer agents being approved. With a new set of biologics entering the market, psoriasis is quickly becoming a dynamic therapeutic area. The newest entrant into the psoriasis market, Novartis’ Cosentyx, was …

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Drivers of Rheumatoid Arthritis Prescription Abandonment

Patient prescription abandonment and medication non-adherence is a major market concern, with estimates of up to one-third of written prescriptions not being filled and projected costs of $290 billion each year from non-adherence1. While more traditional research focuses on prescription fill rates, the Abandonment Insight …

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Biosimilars in Rheumatoid Arthritis: What to Expect?

Rheumatoid arthritis (RA) has traditionally been one of the more competitive markets for new entrants with the TNF-alpha inhibitor class of drugs enjoying a good percentage of the market share. By effectively inhibiting the response to tumor necrosis factor (TNF), a cytokine released during …

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Impact of the entrance of PCSK9i to the hypercholesterolemia market in Q3 2015

Amgen and Regeneron/Sanofi are in a heated race to launch their respective PCSK9 inhibitors (PCSK9i), Repatha and Praluent, late this summer. These new drugs are highly efficacious, reducing LDL cholesterol levels up to an additional 60%, and tout a low instance of adverse events. …

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The “New Normal” of Payer Contracting

An analysis of 26 product approvals from 2011 through early 2015 across 11 distinct therapeutic areas, including 8 specialty and 3 non-specialty categories, indicates that contracting discussions with payers are happening earlier than in past years. In fact, first mentions of contracting negotiations in …

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Patients’ Feelings upon Receiving a New Script Are Related to Whether the Doctor Included Their Opinion about Treatment Options

Consumer Connect, Zitter Health Insight’s newest subscription data service, recently collected some insightful data on patients in the Diabetes space and their feelings when they visit the doctor. The data team collected feedback from diabetes patients that had just gone to visit their physician …

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Some HCV Patients Get More Time with Their Doctor than Others

Hepatitis C is an exciting space with several new market entrants that hold the promise of curing individuals of the disease. Through a point-in-time consumer market research study, Consumer Connect, Zitter Health Insights has gained unique insight into the behavioral patterns of Hepatitis C …

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Zitter Health Insights Introduces Consumer Connect: Understanding the “whys” behind patient behavior

Zitter Health Insights’ newest subscription product, Consumer Connect, generates actionable insights into what influences consumer behavior at key healthcare moments and experiences along the patient journey. By understanding what a patient is thinking at the moment he or she visits the doctor, receives a …

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Asthma Patients Discuss Their New Inhalers With Doctors

Consumer Connect, a new subscription data service from Zitter Health Insights, helps biopharmaceutical companies understand the “whys” behind patient behavior with immediate, point-in-time consumer recall of key healthcare moments. Most recently, the team collected data on doctor visit experiences for asthma patients. Of the …

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Branded Agents Enter Generic Categories while Generics Enter the Specialty Space – How Do Payers Manage?

The anticipated entry of branded injectable cholesterol agents in a hyperlipidemia category predominantly occupied by generic agents is expected to issue a speedy wave of access injunctions. Concurrently, the expected arrival of generic multiple sclerosis agents in a category predominated by branded offerings is …

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Payers Hope for Price Relief on the High Cost of Specialty Medication

The FDA recently posted a non-binding draft guidance Biosimilar approval pathway designed to provide guidance on how much data manufacturers would need to submit for approval. According to FierceBiotech the four categories are1: Highly similar with fingerprint-like similarity, Highly similar, Similar, and Not similar. In …

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Prostate Cancer Leads in Clinical Pathway Adoption and Preferential Treatment

Over the past few years, payers have taken an increasingly aggressive approach in managing oncology care and controlling costs. To aid their goals, payers have implemented a number of utilization management tools, including clinical treatment pathways. These treatment algorithms, aiming to promote standardized, evidence …

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Understanding the United Healthcare Group Co-pay Offset Program Exclusions

As of Jan 1, 2014, United Healthcare Group (UHC) has directed designated specialty pharmacies in the company’s commercial insurance network to exclude the use of copay coupons for drugs in a range of categories.  All told, this exclusion includes more than 30 products across …

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Does physician network breadth in the exchanges differ significantly in four major US cities?

Before we tackle the prompt, let’s discuss the research project providing the context for this inquiry. Zitter Health Insights’ Health Insurance Marketplace/Exchange Monitor team collected data on physician network breadth for federal and state-based marketplace plans for metropolitan statistical areas (MSAs) in a number …

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HCV utilization management landscape in flux

Even though a majority of specialists currently and actively treating HCV patients have already prescribed Sovaldi, forty percent have altered a prescribing decision in HCV to avoid burdensome payer requirements (Figure 1). Figure 1: Treatment Alterations to Avoid UM That percentage only stands to …

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How Frequently Are Manufacturers Discussing Healthcare Reform during Payer Visits … and Do Payers Care?

With key provisions of the Patient Protection and Affordable Care Act taking effect this year, it is no surprise that these significant changes to our nation’s healthcare system are being discussed by biopharmaceutical manufacturers during their interactions with payers.  Data from The Managed Care …

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Diabetes Takes a More Restrictive Role within the Health Exchange Marketplace

Diabetes is a dynamic category, continuously growing to treat the estimated 25 million affected adults in the United States. As disease experts estimate, the number of individuals impacted is expected to continuously increase in the coming years. With the launch of the new health …

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What makes some populations more likely than others to enroll in the new health insurance exchanges?

That’s a pretty broad question, but we can start chipping away at it by looking at subset populations and understanding how they will behave. Diabetes is one of the leading diagnoses among the uninsured population, and as such this chronic disease population is a …

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Diabetes SGLT2 Space Now Has Competition

With its FDA approval in early January 2014, Farxiga (dapagliflozin) joined the diabetes market as the second sodium-glucose co-transporter 2 (SGLT2) inhibitor. Invokana was the first SGLT2 inhibitor in the space, following its approval in March 2013. As a number of products seek approval …

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Thank You for Doing Business With Us For 25 Years

Today we celebrate Zitter Health Insights’ 25th Anniversary. I founded the company as The Zitter Group in 1989 in San Francisco. Since then we’ve worked with more than 80 pharmaceutical companies, nearly all the nation’s health plans, large specialty and retail pharmacies, and a …

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Communication Breakdown Clouding Integration of Pharmacy and Medical Benefits

Even within a single therapeutic area, specialty drugs can be administered in various sites-of-care, coded within a number of systems, and covered under the pharmacy or medical benefit. This cocktail of factors results in a confusing and disjointed method of utilization management, physician reimbursement, …

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Health Exchange Premiums – Are Young People Willing to Pay More?

Zitter Health Insights recently surveyed 3,000 uninsured consumers to understand how different factors influence their enrollment in the health insurance exchanges. We looked at the results from a number of different demographic angles and one in particular stuck out to our team—young people are …

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Meetings with Payers on Multiple Sclerosis Oral Agents Remain Frequent and Competitive

Multiple sclerosis (MS) remains one of the most frequently discussed therapeutic areas between pharmaceutical manufacturers and payers, driven in large part by visits from oral MS agent manufacturers (Figure 1).  Details of such meetings, including payer perception of product messaging, are captured by The …

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New Payer Challenges in a Shifting Hepatitis C Landscape

In a November 4th article, the New York Times heralded the arrival of a new generation of Hepatitis C drugs as “an enormous public health achievement.” Indeed, over the next few years several drugs are expected to come to market that significantly aim to improve patient …

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Reflections from a Health Exchange Researcher: Part 2

Now that a full month has passed since the opening of the Health Exchange Marketplace, there has been some more clarity into the variety of plans available. What is still somewhat unclear, is the impact that all these plan types may have on patient …

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Drug Prices vs. Pharmaceutical Spending

Drug pricing and drug expenditures are frequently criticized for being too high. But many Americans don’t distinguish between the two. They are quite different, and the difference matters. There’s no question that most branded drugs tend to have high prices, especially those developed via …

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Dazed and Confused (and Still Uninsured)

I readily confess to not having listened to one minute of live coverage of the 21-hour marathon recently conducted by Ted Cruz on the Senate floor in an attempt to derail funding for the Affordable Care Act (ACA).  It’s not that I don’t appreciate …

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How Much Will A Health Plan from the Marketplace Really Cost Me?

With the health insurance marketplace now open and enrollment underway, this is the question on many individuals’ minds. How much does it really cost for a plan? There are not only monthly premiums to consider, but also co-pays, co-insurances, and out of pocket maximums …

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Reflections from a Health Exchange Researcher

With week 1 of the Affordable Care Act (ACA) officially behind us, a few key themes have emerged. The first is that there are a lot of plans. Based on data released from healthcare.gov, Federal and Joint Run plans alone total over 2,200 individual …

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Changing Landscape in Oncology – Chronic Myelogenous Leukemia (CML)

Similar to prostate cancer, CML is a disease that is benefiting from recently approved oral drug entrants. Bosulif and Iclusig are two new tyrosine kinase inhibitors (TKIs) approved for the treatment of CML. With the approvals, this makes CML a disease where there are …

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Competitive Discussions Most Common in Asthma and Chronic Obstructive Pulmonary Disease Messaging

With many approved respiratory therapies, both asthma and chronic obstructive pulmonary disease (COPD) manufacturers have numerous potential points of comparison when messaging to payers about their respective agents.  As companies seek to detail and differentiate their products, The Managed Care Message Monitor captures the …

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The Other Health Insurance Exchanges

The Wall Street Journal reported recently in a front-page article that IBM will transfer all of its retiree health benefits to a privately operated health insurance exchange. IBM will continue to subsidize retiree healthcare, but as of December 31, 2013 will no longer select …

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How Do Payers Design Their Exchange Plan Offerings?

As payers finalize their plans for approaching the health insurance exchanges, many in our industry are wondering—will payers treat the exchanges like an extension of commercial? Will management be more restrictive due to anticipated adverse selection in the enrollee pool? Will certain disease states …

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Why the R&D Productivity Debate Matters to Everyone – Including Payers

You may have seen some of the recent commentary urging heads of R&D departments at Merck and other major pharmaceutical manufacturers to cut R&D spending.  Many of the arguments cite R&D productivity statistics and industry benchmarks for determining the success of these R&D programs.  …

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What Coverage Payers Expect to Offer in the Exchanges

Mere months away from the January 1, 2014 operational deadline for health insurance exchanges, and just weeks away from the October 1 open enrollment date, payers are pressured to finalize their health insurance exchange plans. Confusion regarding these marketplaces still exists among consumers, employers, …

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Competitive Discussions Prevalent in Therapeutic Areas with New Entrants

Many new drugs have been approved over the past year, and The Managed Care Message Monitor has captured the resulting impact on respective category discussions.  Recent new entrants in a plethora of therapeutic areas have increased competitive discussions for such categories to an extent …

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Finding Common Ground Among Stakeholders on Co-Pay Assistance Issues

Co-pay assistance programs are one of the most controversial topics in the managed care and biopharmaceutical industry today.  The debate is rich with issues surrounding co-pay program motivations, impact and outcomes.  Proponents of co-pay offset programs argue that these programs increase access and adherence.  …

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Xeljanz Begins to Take a Role within the Rheumatoid Arthritis Marketplace

Rheumatoid Arthritis is a dynamic category with a robust pipeline, expecting many new agents over the next few years. Xeljanz, the first oral treatment in Rheumatoid Arthritis launched in November 2012, has gradually begun to take a role in the highly competitive Rheumatoid Arthritis …

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Biosimilar Growth in Europe Transcends to America

Attention to biosimilars within the United States has been gaining momentum as their utilization in Europe continues to grow. In the recently published Spring 2013 Managed Care Biologics and Injectables Index, payers continue to anticipate biosimilars impacting specialty category management within 2 years. This …

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Assessing the Value of Pharmaceuticals

With healthcare costs continuing to rise, and key elements of the Affordable Care Act coming on line, the idea of measuring the value of pharmaceutical therapy has gained new traction. The notion is that we should determine what works best and then pay only …

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Marketing Innovation in Rheumatoid Arthritis Offers a “Money Back Guarantee”

Co-pay offset programs have evolved from incentives to try a particular therapy into interactive centers for which patients can receive many different types of support.  When patients “opt in” to co-pay programs for Rheumatoid Arthritis, they receive additional benefits such as counseling and support, …

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Media Emphasis on Limited Insurer Options in Exchanges Misleading

In recent weeks, several states have released the names of carriers applying to sell health insurance on the marketplaces/exchanges (HIX) during their first year of operation. One theme that has emerged in coverage of exchanges is the limited number of carriers expected to participate …

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Multiple Sclerosis Oral Agent Meetings Plentiful Following New Category Entrants

Payers rank multiple sclerosis among their top five specialty category management priorities over the past three years and anticipate that the space will remain a top concern over the next twelve months, as reported in The Managed Care Biologics and Injectables Index.  This sustained …

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Sales Rep Lay-Offs Mask the Real Transition in the Pharma Sales Role

Eli Lilly recently announced that it would cut up to 40% of its U.S. based sales force, as many as 1,624 salespeople. The layoffs were made in anticipation of Cymbalta’s patent loss in December of this year, shortly following Zyprexa’s loss of exclusivity. Eli …

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Payers Starting to Drive Preferred Agent Use in Osteoarthritis

Similar to immunoglobulin agents, payers see little differentiation between specialty agents within the Osteoarthritis category. With payer perception that agents are equivalent in safety and efficacy, combined with the high cost of these agents, Zitter believes the Osteoarthritis category is ripe for payer focus …

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Patient Co-Pay Assistance Solutions for the Medicare Population

The Federal Anti-Kickback Rule creates challenges for manufacturers trying to reach Medicare patients with patient access programs.  The Anti-Kickback Rule essentially makes illegal the furnishing of any item or service for which payment may be made in whole or in part under a Federal …

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Payers and Oncologists Investigate Excess Cost

It appears the decision by Sloan-Kettering (announced in an October 14, 2012 op-ed piece in the New York Times) not to give Zaltrap (ziv-aflibercept) to its patients blew open the door for physicians and others to publicly decry the costs of new pharmaceuticals.  In …

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Pfizer Rheumatoid Arthritis Payer Meetings Soar Following Xeljanz Approval

Payers consistently rank rheumatoid arthritis among their top specialty category management priorities, as evidenced in The Managed Care Biologics and Injectables Index.  This pattern has not changed following the November 2012 approval of oral agent Xeljanz, which brought a new dynamic to the already …

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What Drives the Cost Impact of Healthcare Reform?

The Society of Actuaries released research last month that predicts claims costs will increase by an average of 32 percent for the individual health insurance marketplace by 2017. The estimate hinges largely on a number of key drivers that are, as of yet, fluid …

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A New Co-Pay Offset Program Strategy for Patient Access: Direct Programs

Co-pay offset programs come in many shapes and sizes.  There are coupons, debit cards, automatic programs, buy & bill programs, pharmacy reimbursement and membership account programs.  A new program type, the direct program, is surfacing.  Manufacturers send the drug directly to the patient via …

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Who Will Enroll in Health Insurance Exchanges (HIX)?

This is the big question tormenting payers, PBMs, pharma companies, and other large healthcare stakeholders. It’s not hard to understand why. As many have pointed out, Health Insurance Exchanges (HIX) represent the first substantial change in our healthcare system since Medicare introduced Part D …

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Oncology Trends: On a Whole, Payers Changing Slowly

With a multitude of changes impacting the oncology delivery system, not the least of which are heath care reform-driven reimbursement initiatives, it’s not surprising to see drastic changes in payer management of oncology.  A quick scan of the news reveals plenty of these major …

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Payers Starting to Show Preference with Prostate Cancer Agents

The lack of curative therapies for advanced or recurrent prostate cancer leads to a focus for more effective targeted therapies among manufacturers. The prostate cancer category has one of the most robust pipelines with over 100 compounds in development. The most recent drug launch …

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Healthcare Cost Management- What’s Missing from the Dialogue?

The recent Time Magazine article, “Bitter Pill- Why Medical Bills are Killing Us,” by Steven Brill has spurred a debate and ongoing commentary overnight. My guess is that many of you have seen Mr. Brill’s article, the follow-on Letters to the Editor, and Brill’s …

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Why is Healthcare Cost Growth Slowing?

With the incessant drumbeat of news about rising healthcare costs, it’s easy to miss the surprising fact that cost increases have dropped substantially. That’s not to say that if current trends continue, our cost problems will be solved. However, it’s critical to try to …

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Diabetes DPP4 Messaging Focuses on Product Access

Manufacturers continue to compete for market share in the heavily populated diabetes DPP4 class.  The Managed Care Message Monitor (MCMM) is the only broad-based service of payer decision-makers that reports perceptions of visits between payers and biopharmaceutical representatives, including those that occur in the …

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Health Exchange Impact on Benefit Design

Nearly 40% of employers plan to drop coverage for current employees beginning in 2014.  This trend portends a significant shift of people into health exchanges who were expected to maintain employer-sponsored coverage.  Whether employers actually go through with their intent and pay the penalty …

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The Zitter Group Rebrands as Zitter Health Insights

The Zitter Group has rebranded as Zitter Health Insights.  The new name more accurately represents our core competence in syndicated market research on payer influence on access for life sciences products.  As the managed markets landscape became more complex, we began to offer insights …

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New Tools for New Rules

The game has changed. Payers have long attempted to influence the prescribing and use of pharmaceuticals in ways they believe are best for their members and plan sponsors. Health plans and pharmacy benefit managers naturally see this as part of their mission – providing …

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Health Plans and PBMs Take Action to Limit Utilization of Co-Pay Offset Programs

A disturbing trend is emerging in the co-pay assistance marketplace as marketers managing co-pay offset programs face increasing resistance from payers and pharmacy benefits managers (PBMs).  Payers and PBMs complain that co-pay offset programs raise costs by encouraging the use of branded drugs over …

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A Unique Service Supports Bio-Pharma Manufacturers Increasingly Challenged to Assess the Impact of Payer Management on New Product Introductions

Changes in the healthcare environment and payer access management of new products have resulted in increased pressure on bio-pharma manufacturers’ launch campaigns.  During development and 6-24 months prior to a commercial launch, manufacturers are increasingly challenged to plan for the impact of payer management …

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A Critical Piece to the Co-Pay Offset Puzzle: Pharmacist Perspectives on Co-Pay Offset Programs

Pharmacists play an important role in the operations of co-pay offset programs, both by processing co-pay coupons and by educating patients about co-pay offset programs.  We recently conducted in-depth interviews with twenty-one pharmacists to gather information about their perceptions of co-pay offset programs and …

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Co-pay Offset Programs: Separating Fact from Fiction

Are all co-pay offset programs directed at shifting market share to higher cost drugs?  Do they have any impact on patient access or adherence? Co-pay offset programs – manufacturer-sponsored discounts that reduce patient cost sharing – have become a dominant marketing tool available to …

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Mixed Response to Avastin’s Indication Removal for Breast Cancer

The removal of Avastin’s FDA approved indication as a first-line breast cancer treatment brings mixed reactions by payers and oncologists almost one year after the revocation. Both NCCN and CMS have stated that they will support Avastin’s use as a first-line breast cancer treatment, …

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New Control Techniques on the Horizon for Payer Oncology Management

Despite a consensus increase in management aggressiveness over the past two years, payers have not seen a corresponding rise in effectiveness, opening the door for new control techniques in the future management of oncology. Payer-reported levels of oncology management aggressiveness have increased substantially over …

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Cost-Sharing and PA Rates Differ between Medical and Pharmacy Benefit

Despite a plurality of payers reporting a disparity in cost-sharing levels and prior authorization rates for agents covered on the medical versus the pharmacy benefit, there is little attempt to reconcile the issue. Payers report that both prior authorization rates and cost-sharing amounts tend …

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Cost Concerns Continue to Dominate Benefit Design

To combat rising costs, payers look to increase utilization management and raise member premiums. Employers shy away from restricting utilization, but are on board with shifting cost-share to employees. Both payers and employers report that total medical and pharmacy costs, as well as disease …

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