Rheumatoid Arthritis/Systemic Lupus Erthyematosus | Access and Reimbursement | US | 2016

Rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) are chronic and, in many cases, debilitating diseases requiring lifelong treatment. Costs associated with biologic treatment for RA patients not successfully managed on conventional disease-modifying antirheumatic drugs (DMARDs) can be in excess of $30,000 per year. In the effort to curb escalating drug costs associated with treating these chronic, progressive conditions, many health insurers have turned to narrow provider network arrangements and clinical pathways that encourage prescribers to use preferred agents and to achieve cost-control targets. This report focuses on the effect of narrow provider networks and clinical pathways on the use of branded drugs treating moderate to severe RA and SLE. RA is a crowded category of branded biologic drugs, led by three of the longest-used biologic agents: etanercept (Amgen/Pfizer‘s Enbrel), infliximab (Janssen’s Remicade), and adalimumab (AbbVie’s Humira)—all TNF-alpha inhibitors. More-recent agents studied include certolizumab pegol (UCB’s Cimzia), tocilizumab, (Roche’s Actemra), abatacept (Bristol-Myers Squibb’s Orencia), and rituximab (Biogen Idec/Roche’s Rituxan). An oral nonbiologic, tofacitinib (Pfizer’s Xeljanz), is the most recent arrival on the market (2012). Treatment of advanced SLE includes off-label use of DMARDs including Genentech’s CellCept and the B-cell modulator Rituxan, as well as a relatively new rheumatologic agent, belimumab (GlaxoSmithKline’s Benlysta).

Questions Answered:

  • Clinical pathways—which identify preferred drugs for use at each stage of treatment—are mostly known for their use in oncology indications; however, some health plans and providers are also using pathways for RA and SLE, and many anticipate doing so within the next ten years. What outcomes related to clinical pathways have been noted by payers that have used them for autoimmune conditions? How do plans encourage physicians to follow clinical pathways and what is the average targeted compliance rate? What attributes of a drug are important to payers and physicians when determining which drugs should be included in pathways?
  • Survey results show that clinical pathways often follow the step therapy profile of the insured member’s health plan. What are the most common restrictions on RA and SLE drugs imposed by payers? What are the successes and stumbles of specific drugs to treat these conditions, based on physicians’ reactions to access and reimbursement issues?
  • Narrow networks—a network of healthcare providers that is a smaller subset of a broader provider network—have become a familiar feature in low-cost health plans for individuals and small groups. How do managed care organizations (MCOs) select rheumatologists to participate in their narrow networks and what conditions must they meet to stay in these networks? What impacts on prescribing patterns do MCO officials expect to result from narrow network participation, and what are the actual impacts as reported by rheumatologists for drugs treating RA and SLE? Are separate formularies used for narrow network plans?


Markets covered: United States.

Primary research: Online survey of 101 rheumatologists, 37 MCO medical directors, and 26 MCO pharmacy directors.

Commercial context: Epidemiology tables, drug-treatment algorithms, and managed care background information.

Therapies covered: Drugs used for the treatment of RA and SLE in the following categories: TNF-alpha inhibitors, B-cell-targeted therapies, selective costimulation moderators, IL-6 inhibitors, IL-1 inhibitors, and Jak inhibitors.”

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