Formulary Advantages in Immune Biologics: Tightening Payer Control Offers Opportunities for Differentiation

Biologics used
to treat immune diseases cost much more than their small-molecule counterparts,
and so their use involves costs disproportionate to the number of patients
treated. As a result of this disconnect between cost and number of treated
patients, managed care organizations (MCOs) seek to limit the overall use of
immune biologics. That just four of these biologics (Amgen/Wyeth’s Enbrel
[etanercept], Centocor Ortho Biotech’s Remicade [infliximab], Roche’s Rituxan
[rituximab] and Abbott’s Humira [adalimumab]) together garner over $9.5 billion
in annual sales in the Unites States alone makes immune biologics a massive
target for cost reduction by payers. More than for other groups of drugs,
reimbursement is a key barrier to entry and differentiating feature of immune

Using tiering
and restrictions data from Fingertip Formulary, as well as insight from 40
pharmacy directors, this report determines the key trends in reimbursement of
immune biologics, drivers of these trends, and how stakeholders can capitalize
on future shifts in coverage to steal share from the competition.