Access Market Intelligence (AMI), in collaboration with EPIC (Employer-Provider Interface Council), a non-profit council of the Hospital Quality Foundation (HQF, 501c3), works with biopharma companies to gain a deeper understanding of the market landscape, including employers’ benefit coverage decisions and the impact those decisions have on the market for rare disease / orphan drugs.
Orphan drugs or related therapies today already are nearly half of the “specialty” drugs that achieve FDA expedited or standard approval. However, because of their high costs and low patient volume, concerns are raised by plan sponsors about access, pricing, distribution contracts, and value.
Health plan members with rare medical conditions have higher total health care costs overall that impact employer benefit coverage decisions. Employers are increasingly using various carve-outs, eliminating or terminating coverage for drugs used in rare diseases from the employer’s health benefits. Biopharma manufacturers need to know that this trend will only increase in the future.
Several innovative financing mechanisms for rare disease programs are being discussed, developed, or introduced for employers to consider adopting. Some employers have adopted stop loss or reinsurance policies as one mechanism to help manage orphan drugs, high variable claims, and unanticipated costs that can be associated with rare diseases.
Biopharma companies need to see the employer market clearly in the short and long-term to be able to identify and understand payers current and anticipated management methods for orphan drugs and the impact those decisions will have on their drugs.
AMI and EPIC collaborate with biopharma companies to help them gain a better understanding of the commercial insured employer market landscape and what drives the medical or pharmacy benefit coverage decisions impacting access for patient use.
Contact Dr. Randy Vogenberg (firstname.lastname@example.org) or myself 203-377-0460 (email@example.com) to discuss how these real-world market trends may already be effecting your anticipated market access.