According to the MagellanRx Pharmacy Trend Report, specialty pharmaceuticals account for 96% of drug spending in commercial plans, prescribed to only 30% of patients. Additionally, the late-stage drug pipeline is loaded with specialty pharmaceuticals. For these reasons, payers are aggressively managing the soaring trend in pharmaceutical costs. In other words, payers are levering the pharmacy practice tools at their disposal to their fullest capabilities, to manage these costs.
For pharmaceutical accounts executives, knowing which plans cover your product (and your competitors’), how they cover it and what utilization management is applied to curb its use is critical.
The crucial question for any pharmaceutical manufacturer is whether your product will attain coverage on target plans’ or pharmacy benefit managers’ (PBMs) formularies. However, scoring a tier three or preferred brand placement is one thing, but avoiding onerous prior authorization (PA) or step-edit requirements is critical to optimizing your drug’s market share. We know the launch of new pharmaceuticals can change formulary placement as innovative, enticing contracts are written by their manufacturers.
Depending on the individual state regulations, plans may change their formularies multiple times each year, particularly to add new coverage.
On the other side of the fence, payers and PBMs want up-to-date information on how their competitors are addressing the same questions they struggle to answer: How do they provide access to a drug that may be high cost, high risk or simply the third entrant to a drug category? Do they cover the drug on the pharmacy benefit or medical benefit? Is it stepped through another agent considered to have higher value by the plan?
Actionable Information on Formulary Positioning
The key to having actionable payer coverage information is the accuracy of the information. Most stakeholders would prioritize having current, reliable data. However, there are other important considerations in gaining and using this information.
For one, tier names are evolving: In modern health plans, tier two may refer to “nonpreferred generics,” whereas it was typically synonymous with “preferred brands” only a few years ago. Today, many plans have a preferred and even a nonpreferred specialty drug tier. Therefore, tier three for one plan may not mean the same thing as tier three in another, if the plans or PBMs number the tiers at all.
Understanding formulary placement within the pharmacy versus medical benefits is another source of confusion. Biosimilars placements are a notable example. Excluding insulin products, most of the 27 marketed biosimilars approved by the Food and Drug Administration as of August 4, 2022, have been covered under the medical benefit. Pegfilgrastim may be an exception. This injectable product is used primarily to prevent infections in patients receiving cancer chemotherapy. However, some plans may cover the five biosimilar pegfilgrastim products and their reference product, Neulasta®, under both the medical and pharmacy benefit.
Answering These Questions with Formulary Viewer
This is where the Formulary Viewer excels. We have upgraded the capabilities of this market intelligence tool to allow subscribers to achieve new levels of data granularity.
Do you need to know how several key plans cover Product X? Through Formulary Viewer’s intuitive user interface and dashboards, queries provide specific formulary tiering that can be filtered geographically with an unlimited number of plans per query.
If you seek regional or national data, Formulary Viewer calculates the cumulative number of pharmacy lives (formulary level) and links this figure to formulary tiering, PA and step edit requirements, and the percentage of the plan population under those utilization management restrictions for each drug. The database includes formulary data across:
- Commercial insurers
- Self-funded plans
- Medicare Advantage plans
- Managed Medicaid
- Medicaid fee for service
- Veterans Affairs system
- Worker’s compensation benefit plans
Formulary Viewer will indicate whether the drug is covered under the medical benefit or the pharmacy benefit. Up to 20 drugs can be queried at once.
With updates on a rolling, 48-hour basis, Formulary Viewer supplies in-depth formulary reporting and analytics through a unique, patent-pending technology to ensure your constantly accessing a live state of the rapidly changing market.