Health Exchanges and Multiple Sclerosis | Physician & Payer Forum | US | 2015

How Are Payers Responding to High-Cost Therapies on Their Exchange-Based Plans?
The Affordable Care Act (ACA) has expanded access to insurance coverage to millions and has reformed health insurance requirements to assure more-comprehensive coverage of behavioral health and prescription drugs. Government reports estimate that more than 8 million people have enrolled in a health plan offered on the health insurance exchange, including 5.8 million estimated to have made their first payments. In addition, as many as 8 million people have gained coverage through the expansion of Medicaid in 27 states and the District of Columbia, creating a new, lucrative sales channel for the pharmaceutical industry. These changes stand to affect reimbursement and prescribing of therapies treating MS, an indication that largely strikes younger individuals who do not qualify for Medicare, and are therefore recipients of commercial coverage, Medicaid, or are uninsured. Expanded coverage means that individuals who were previously uninsured or who had access to less-generous commercial plans can now obtain insurance via exchange-based plans or Medicaid. As a result, demand for MS therapies should increase. However, the desire by MCOs to limit adverse selection in their exchange-based plans may also limit access to some therapies that are not preferred by payers, affecting uptake. MS therapies used include Bayer HealthCare’s Betaseron (IFN-β-1b), Novartis’s Extavia (IFN-β-1b), Biogen Idec’s Avonex (IFN-β-1a, IM), Merck Serono/EMD Serono’s Rebif (IFN-β-1a, SC), Biogen Idec’s Plegridy (pegylated interferon-β-1a), Teva’s Copaxone (glatiramer acetate), Biogen Idec’s Tysabri (natalizumab), Novartis/Mitsubishi Tanabe Pharma’s Gilenya (fingolimod), Genzyme’s Aubagio (teriflunomide), and Biogen Idec’s Tecfidera (dimethyl fumarate).

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