Rheumatoid Arthritis & Psoriatic Arthritis | Access and Reimbursement | Indication-Specific Pricing | US | 2017

Two of the largest pharmacy benefits managers (PBMs) in the United States, Express Scripts and CVS Health, have set traditional U.S. drug reimbursement on its head by introducing indication-specific pricing. Instead of reimbursing a drug the same way across all indications for which it is approved, these PBMs have set up programs to vary reimbursement and formulary placement of some drugs based on their clinical value in different indications or patient subpopulations. This study examines the potential for this strategy to take hold with managed care organizations (MCOs), particularly for coverage of autoimmune drugs, one of the biggest drivers of pharmacy costs for U.S. payers. This game-changing strategy means that rheumatoid arthritis (RA) blockbusters such as Enbrel and Humira could face more competition from lesser-known niche products in certain autoimmune indications, such as psoriatic arthritis (PsA).


  • What is the future for indication-specific pricing in the autoimmune category and are any MCOs employing this strategy now?
  • What are or will be the major challenges involved in varying pricing and/or coverage by indication?
  • What indications do MCOs believe would be appropriate for a variable reimbursement strategy and how would they assess value?
  • Do physicians perceive autoimmune drugs as having a different value for different indications that would make them good candidates for indication-based pricing?


Access & Reimbursement: Provides in-depth insight regarding the impact of payer policy on physician prescribing behavior so you can build your market access strategy and optimize your brand positioning.

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