Predicting Payer Uptake With Precision

Today's guest post comes from Carolyn Zele and Ritupriya Yamujala, Senior Solution Consultants at MMIT.

Carolyn and Ritupriya discuss the challenges that manufacturers face in getting payer coverage for new drugs. They argue that a manufacturer can use analogs to improve messaging to payers, identify coverage challenges, and accurately predict payer uptake.

To learn more about these techniques, register for MMIT’s April 6, 2021 webinar: Predicting Payer Uptake With Precision.

Read on for Carolyn’s and Ritupriya’s insights.
Predicting Payer Uptake With Precision

By Carolyn Zele, Senior Solution Consultant, and Ritupriya Yamujala, Senior Solution Consultant, MMIT.

All drug manufacturers know that market access is getting harder and more complicated every year. Over the past five years, as the complexity and cost of drugs coming onto the market have grown, payers have been setting increasingly more aggressive blocks and difficult exception processes on drugs at launch.

As a result, launch predictability is getting more difficult as well, not just for highly complex or costly drugs but for all drug launches, as MMIT’s Carolyn Zele and Ritupriya Yamujala will discuss at a meet the expert webinar, Predicting Payer Uptake With Precision on April 6, 2021.

Payer review strategies have been changing to accommodate the increased need for control as well. The sheer volume of drugs on the market to be reviewed and monitored has increased exponentially, and the FDA seems to be approving drugs faster than ever. The ability for a payer’s P&T committee to review all new drugs quickly and efficiently depends not only upon the cadence of their P&T meetings but more importantly on their prioritization process. Additionally, payers may also be allowing time for contract offers and negotiations with manufacturers prior to P&T review.

MMIT has found that most commercial and Medicare plans, representing over 69% of lives, can still make a coverage decision within the first quarter of a drug launch, while Medicaid payers covering 40% of lives take an average of nine-plus months to review a newly approved agent. Payers vary by channel in how they control newly launched drugs. PBMs are the most restrictive, with almost 95% of enrolled members unable to access a newly launched drug. That percentage drops to 40% for health exchange plans and 30% for Medicare plans. The percentages are much lower for Medicaid, with managed Medicaid plans representing just 15% of lives not covering drugs at launch.

The percentage of commercial payers blocking access to a new drug at launch has risen. In the first quarter of 2015, payers representing 19% of commercial lives did not cover new drugs at launch, but that percentage rose to 41% in the first quarter of 2017, and by the third quarter of 2020, it was nearly 60%. Some of these payers even have created mandatory six-month blocks.

Will payers drag their feet and wait for your rebate offer, or will they prioritize your new drug for review within the first 90 days? Predicting how payers will respond to your drug launch so that you can set the right expectations for your drug’s performance has become an art.

Using an analog drug launch to predict uptake is a widely used method of trying to understand your drug’s launch trajectory. With the sheer volume of drugs launched post-2015, we now have a deep well of analog data to examine. How do you select the right analog drugs to predict your launch with the accuracy your leadership needs and the targeting precision your account team requires? When we examine the criteria P&T committees use to prioritize drug reviews and make coverage determinations, we can find those criteria that will help us select the right analog drugs.

Join MMIT’s Carolyn Zele and Ritu Yamujala for a meet the expert conversation, Predicting Payer Uptake With Precision and learn how to:

• Select the right analogs to accurately predict payer uptake of your drug
• Identify FDA designations, for example breakthrough and fast track, that have the potential to help or hurt your launch trajectory
• Use payer P&T discussions and the decision-makers’ own attitudes and views to anticipate which value story might generate the greatest interest
• Pinpoint the challenges you may need to overcome to get your drug covered

Register for the webinar, Predicting Payer Uptake With Precision.

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