The market access “sweet spots” where payers reimburse more convenient therapies

U.S. payers often say they “don’t pay for convenience,” yet across several therapeutic areas, long-acting injectables (LAIs) command premium prices and broad coverage. In areas like HIV prevention, hemophilia A and opioid use disorder, coverage decisions are heavily shaped by policy and federal mandates. These are therapeutic areas where payer leverage is more limited. It’s important not to assume the same dynamics will apply to your therapeutic area.

Case Study 1: HIV Pre-Exposure Prophylaxis (APRETUDE vs. generic daily oral TDF/FTC)

APRETUDE is a long-acting injectable for HIV pre-exposure prophylaxis (PrEP). Its annual list price is about $25,000 per year—roughly 70 times higher than generic oral TDF/FTC. Despite the price gap, payers cover APRETUDE on par with oral generic options due to federal mandates.

Under the Affordable Care Act (ACA), PrEP is designated a U.S. Preventive Services Task Force (USPSTF) Grade A service.^[1] This requires most commercial and ACA health plans to cover all FDA-approved PrEP products – including APRETUDE – with zero cost-sharing.^[2] Plans cannot impose step therapy, prior authorization, or adherence-based restrictions. As a result, APRETUDE is reimbursed at its established price under the mandate, independent of payer preference.

Case Study 2: Hemophilia A Prophylaxis (ALTUVIIIO vs. Extended Half-Life Factor VIII Replacement)

ALTUVIIIO, an extended half-life (EHL) factor VIII product for hemophilia A prophylaxis delivers near-zero bleeding rates with a once weekly IV injection. Its annual list price approaches $1 million (assuming 70kg), while other EHL products such as ELOCTATE, JIVI, and ADYNOVATE range from $600,000-900,000 per year.^[3] These IV products are typically administered 1-3 times per week and delivered median bleed rates of 1 to 2 per year in clinical studies.^[4]

While ALTUVIIIO’s efficacy data suggest slightly lower bleeding rates, the incremental clinical benefit may not fully justify the significant list price premium. The cost of treating each additional bleed would need to be $50K to $400K to offset the added cost.

Yet ALTUVIIIO enjoys comparable coverage to other EHL therapies.^[5] In hemophilia, payers tend to apply minimal utilization management due to the condition’s rarity, severity, and high public visibility.  Payers can be hesitant to apply access restrictions when there are a limited number of hemophilia treatment centers to treat their members. In this setting, premium pricing reflects payers’ limited leverage rather than proportional clinical superiority.

Case Study 3: Opioid Use Disorder (SUBLOCADE and BRIXADI vs. Generic Daily Orals)

Long-acting buprenorphine injectables SUBLOCADE (monthly) and BRIXADI (weekly or monthly) have an annual list price of $20,000–$25,000, versus about $1,000 annual list price for daily generic buprenorphine. Despite the price gap, Medicaid must cover all FDA-approved medications for opioid use disorder under the SUPPORT Act (2018).^[6] According to Clarivate Fingertip Formulary data, SUBLOCADE and BRIXADI have achieved over 99% coverage across commercial, Medicare Advantage, and Medicaid plans that include both pharmacy and medical benefits.

Conclusion

Across HIV, hemophilia A, and opioid use disorder, long-acting injectables (LAIs) often achieve higher prices and broad coverage because payers have limited leverage in these therapeutic areas. These represent “sweet spots” where payers are largely hands-off and coverage is policy-driven. Looking ahead, value frameworks should clearly differentiate between adherence-driven benefits and policy-mandated coverage to better reflect true payer decision dynamics.

 Clarivate’s experienced market access and pricing experts can help you analyze, optimize, and tailor your strategy to maximize commercial success. Visit us to learn more or connect with our experts: Healthcare Commercial Consulting Services | Clarivate

[1] USPSTF recommendation of Grade A for PrEP. Link

[2] KFF Preventive Services Covered by Private Health Plans under the Affordable Care Act. Link

[3] Pricing from NAVLIN database; assumes 70 kg adult and no wastage

[4] Highlights of Prescribing Information for ELOCTATE, JIVI, and ADYNOVATE

[5] Clarivate Fingertip Formulary. Accessed in October 2025. List price: IBM Redbook.

[6] CMS Guidance about Expanded Medicaid Coverage for Treatment of Opioid Use Disorders. Link

Biopharma Commercialization FDA HMO Launch Managed care Market Access MCO North America Payer PBM pricing Route of administration U.S.

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