{"id":574085,"date":"2026-02-02T17:11:44","date_gmt":"2026-02-02T17:11:44","guid":{"rendered":"https:\/\/clarivate.com\/life-sciences-healthcare\/?p=574085"},"modified":"2026-03-10T09:29:19","modified_gmt":"2026-03-10T09:29:19","slug":"what-healthcare-payers-reward-adherence-versus-outcomes","status":"publish","type":"post","link":"https:\/\/clarivate.com\/life-sciences-healthcare\/blog\/what-healthcare-payers-reward-adherence-versus-outcomes\/","title":{"rendered":"What healthcare payers reward: adherence versus outcomes"},"content":{"rendered":"<p>Many companies developing alternative drug delivery systems start with a common question: <em>\u201c<\/em><em>If our therapy improves adherence or convenience, will payers reward it with a price premium<\/em><em> or better access<\/em><em>?<\/em><em>\u201d<\/em><\/p>\n<p>It\u2019s an appealing idea \u2014 better convenience should lead to better adherence, which should mean better outcomes, right? In practice, however, payers rarely pay for <em>convenience<\/em>. They pay for <em>outcomes<\/em> that can be measured as cost savings within their budget horizon, typically one to two years.<\/p>\n<p>Two case examples illustrate the difference between the \u201cadherence premium\u201d and the \u201coutcome premium.\u201d<\/p>\n<p>&nbsp;<\/p>\n<h3><strong>Case Study 1: NEULASTA on-body device \u2014adherence and outcomes drive advantage in a highly competitive, rebate-driven market<\/strong><\/h3>\n<p>NEULASTA Onpro, an on-body device (OBD), automatically releases pegfilgrastim around 27 hours after chemotherapy, eliminating a return clinic visit for administration.<sup><a href=\"#_edn1\" name=\"_ednref1\">[1]<\/a><\/sup> The Onpro kit has an Average Sales Price (ASP; the list price exclusive of rebates, discounts, and other factors) of $1,072.<a href=\"#_edn2\" name=\"_ednref2\">[2]<\/a> There are multiple branded and biosimilar pegfilgrastim products available as HCP-administered subcutaneous (SC) injections. The lowest cost option is biosimilar pegfilgrastim ZIEXTENZO with an ASP of $283 per dose.<sup><a href=\"#_edn3\" name=\"_ednref3\">[3]<\/a><\/sup><\/p>\n<p>Will payers offer comparable access to the NEULASTA on-body device when a biosimilar SC injection is available with a ~70% lower ASP?\u00a0 Despite the higher Average Sales Price, <strong>most commercial and Medicare payers advantage access to the <\/strong><strong>on-body device<\/strong><strong> compared to the lowest cost biosimilar.<\/strong><\/p>\n<ul>\n<li>NEULASTA On-Body Device: 50% preferred tier for commercial, 71% preferred tier for Medicare Advantage medical benefit<\/li>\n<li>ZIEXTENZO SC: 4% preferred tier across the board<sup><a href=\"#_edn4\" name=\"_ednref4\">[4]<\/a><\/sup><\/li>\n<\/ul>\n<p>While substantial payer rebate competition exists among Neulasta, Neulasta Onpro, and biosimilars, real-world outcomes data offer compelling evidence to support Neulasta Onpro\u2019s value in payer engagements.<br \/>\nReal-world studies show:<\/p>\n<ul>\n<li>Better adherence: 94% for NEULASTA Onpro vs. 58% for clinic-based SC injections<sup><a href=\"#_edn5\" name=\"_ednref5\">[5]<\/a><\/sup><\/li>\n<li>Lower neutropenia incidence: 6.4% vs. 9.4% over 12-16 weeks<sup>5<\/sup><\/li>\n<li>Avoided hospitalizations: 93% reduction in neutropenia admissions, which cost an average $47K per episode<sup>1<\/sup><\/li>\n<\/ul>\n<p>Those are short-term, measurable outcomes. <strong>Payers can directly link the higher upfront drug cost to fewer expensive hospital admissions within the same fiscal cycle.<\/strong><\/p>\n<p>&nbsp;<\/p>\n<h3><strong>Case Study 2: CABENUVA \u2014 when high adherence leaves no room to improve<\/strong><\/h3>\n<p>CABENUVA, the (bi-)monthly long-acting injectable combination of cabotegravir and rilpivirine for HIV treatment, entered the market with the promise of better adherence through less frequent dosing.<\/p>\n<p>In pivotal clinical trials, CABENUVA demonstrated non-inferiority to daily oral antiretroviral therapy (ART).<sup><a href=\"#_edn6\" name=\"_ednref6\">[6]<\/a><\/sup> CABENUVA\u2019s post-launch real-world study confirmed this: patients switching to CABENUVA had similar virologic outcomes to those who switched to another oral regimen, with no statistically significant difference in failure rates.<sup><a href=\"#_edn7\" name=\"_ednref7\">[7]<\/a><\/sup><br \/>\nThe issue is that while <em>some<\/em> sub-populations of people with HIV have adherence challenges with daily orals, many patients <em>do not<\/em>.\u00a0 Clarivate real-world data analysis indicates that average compliance for daily orals in the US was over 80% in 2024.<sup><a href=\"#_edn8\" name=\"_ednref8\">[8]<\/a><\/sup> \u00a0Patients taking daily oral ART maintained viral suppression rates of 91% versus 95% for CABENUVA in the real-world OPERA study.<\/p>\n<p>CABENUVA\u2019s launch price was higher than its daily oral competitor BIKTARVY when it launched in January 2021 and was significantly more expensive than generic daily orals.<sup>2<\/sup><\/p>\n<ul>\n<li>Cabenuva\u2019s new-to-market block (NTMB) period exceeded the typical market average of 6\u201312 months; it took approximately 17 months for more than 95% of state and managed Medicaid health plans to provide coverage<sup>4<\/sup><\/li>\n<li>Over three years after approval, only 18 (37%) state Medicaid plans provided uniform coverage of CABENUVA with no prior authorization<sup><a href=\"#_edn9\" name=\"_ednref9\">[9]<\/a><\/sup><\/li>\n<\/ul>\n<p>When adherence is already high, the \u201cbetter adherence\u201d argument simply doesn\u2019t translate into incremental value.<\/p>\n<p>The Takeaway: <strong>Payers Pay for Outcomes, Not Intentions<\/strong><\/p>\n<p><strong>Payers don\u2019t pay for <\/strong><strong>\u201c<\/strong><strong>convenience<\/strong><strong>\u201d: <\/strong><strong>they pay for evidence of clinical and economic impact<\/strong><strong> in 1-2 years<\/strong><strong>.<\/strong> In short, the \u201cadherence premium\u201d only becomes an \u201coutcome premium\u201d when the data prove it saves money \u2013 <em>fast<\/em>.<\/p>\n<p><em>\u00a0<\/em><\/p>\n<p><em>Clarivate\u2019s experienced market access and pricing experts can help you analyze, optimize, and tailor your strategy to maximize commercial success.<\/em><em> Visit us to learn more or connect with our experts: <a href=\"https:\/\/clarivate.com\/life-sciences-healthcare\/consulting-services\/commercial-consulting-services\/\">Healthcare Commercial Consulting Services | Clarivate<\/a><\/em><\/p>\n<p>&nbsp;<\/p>\n<p><small><a href=\"#_ednref1\" name=\"_edn1\">[1]<\/a> NEULASTA Onpro website for healthcare providers, accessed October 2025<a href=\"#_ednref2\" name=\"_edn2\">[2]<\/a> NAVLIN pricing database<\/small><\/p>\n<p><small><a href=\"#_ednref3\" name=\"_edn3\">[3]<\/a> Samsung Bioepis Biosimilar Market Report, 10th edition Q3 2025<\/small><\/p>\n<p><small><a href=\"#_ednref4\" name=\"_edn4\">[4]<\/a> Clarivate Fingertip Formulary, accessed in October 2025<\/small><\/p>\n<p><small><a href=\"#_ednref5\" name=\"_edn5\">[5]<\/a> Rifkin R, Crawford J, Mahtani R et al. (2022). A prospective study to evaluate febrile neutropenia incidence in patients receiving pegfilgrastim on-body injector vs other choices. Support Care Cancer. 30 (10). 1-10<\/small><\/p>\n<p><small><a href=\"#_ednref6\" name=\"_edn6\">[6]<\/a> CABENUVA ATLAS and FLAIR clinical trials as described in Highlights of Prescribing Information<\/small><\/p>\n<p><small><a href=\"#_ednref7\" name=\"_edn7\">[7]<\/a> CABENUVA website for healthcare providers, accessed October 2025<\/small><\/p>\n<p><small><a href=\"#_ednref8\" name=\"_edn8\">[8]<\/a> Clarivate HIV Treatment Algorithms: Claims Data Analysis published March 2025<\/small><\/p>\n<p><small><a href=\"#_ednref9\" name=\"_edn9\">[9]<\/a> Zalla LC, Horn T, Lujintanon S, Lesko CR (2025). \u7f8e\u56fd\u5404\u5dde\u5728\u83b7\u53d6\u7528\u4e8eHIV\u6cbb\u7597\u7684\u957f\u6548\u6ce8\u5c04\u7528\u6297\u9006\u8f6c\u5f55\u75c5\u6bd2\u7597\u6cd5\u65b9\u9762\u7684\u5dee\u5f02. Health Aff Sch. Jan 29;3(2)<\/small><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Many companies developing alternative drug delivery systems start with a common question: \u201cIf our therapy improves adherence or convenience, will payers reward it with a price premium or better access?\u201d&#8230;<\/p>\n","protected":false},"author":307,"featured_media":574089,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_links_to":"","_links_to_type":0,"footnotes":""},"categories":[19],"tags":[40,2419,2695,2697,2615,90,2617,2510,2621,333,424,2623,2625],"class_list":["post-574085","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-biopharma","tag-biopharma","tag-consulting-resource-center","tag-hmo","tag-idn","tag-managed-care","tag-market-access","tag-mco","tag-payer","tag-pbm","tag-pharma","tag-pricing","tag-route-of-administration","tag-u-s"],"acf":[],"lang":"en","translations":{"en":574085,"ja":574151},"publishpress_future_workflow_manual_trigger":{"enabledWorkflows":[]},"pll_sync_post":[],"_links":{"self":[{"href":"https:\/\/clarivate.com\/life-sciences-healthcare\/wp-json\/wp\/v2\/posts\/574085","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/clarivate.com\/life-sciences-healthcare\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/clarivate.com\/life-sciences-healthcare\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/clarivate.com\/life-sciences-healthcare\/wp-json\/wp\/v2\/users\/307"}],"replies":[{"embeddable":true,"href":"https:\/\/clarivate.com\/life-sciences-healthcare\/wp-json\/wp\/v2\/comments?post=574085"}],"version-history":[{"count":10,"href":"https:\/\/clarivate.com\/life-sciences-healthcare\/wp-json\/wp\/v2\/posts\/574085\/revisions"}],"predecessor-version":[{"id":574525,"href":"https:\/\/clarivate.com\/life-sciences-healthcare\/wp-json\/wp\/v2\/posts\/574085\/revisions\/574525"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/clarivate.com\/life-sciences-healthcare\/wp-json\/wp\/v2\/media\/574089"}],"wp:attachment":[{"href":"https:\/\/clarivate.com\/life-sciences-healthcare\/wp-json\/wp\/v2\/media?parent=574085"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/clarivate.com\/life-sciences-healthcare\/wp-json\/wp\/v2\/categories?post=574085"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/clarivate.com\/life-sciences-healthcare\/wp-json\/wp\/v2\/tags?post=574085"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}