{"id":32316,"date":"2024-06-12T11:44:59","date_gmt":"2024-06-12T15:44:59","guid":{"rendered":"https:\/\/avalere.com\/?p=32316"},"modified":"2024-06-12T12:17:23","modified_gmt":"2024-06-12T16:17:23","slug":"patterns-in-patient-access-to-ms-drugs","status":"publish","type":"post","link":"https:\/\/advisory.avalerehealth.com\/insights\/patterns-in-patient-access-to-ms-drugs","title":{"rendered":"Patterns in Patient Access to MS Drugs"},"content":{"rendered":"

Medicare Part D and commercial plans face pressure to curate a formulary for pharmacy benefit drugs amidst growing healthcare costs. The Centers for Medicare and Medicaid Services (CMS) offers various flexibilities for Part D plans to manage their benefit through formulary design (e.g., drug coverage, tiering) and utilization management (UM) (e.g., prior authorization, step therapy). These flexibilities are common across most markets of health insurance coverage for prescription drugs and are increasingly used in Part D<\/a>. While CMS has oversight over Part D plan formularies, plans have considerable flexibility to design formularies that aim to balance patient access and plan cost.<\/p>\n

While Part D plans are required to cover all drugs and are limited in the use of utilization management (UM) in the six protected classes, they are free to exclude products from their formularies or implement UM requirements in other classes to manage their spending and reduce premiums. In particular, non-protected classes that include higher cost drugs, including those for multiple sclerosis (MS), can be a formulary area of focus for Part D plans aiming to limit drug costs.<\/p>\n

Analysis Details<\/h2>\n

Avalere was commissioned to evaluate Part D vs. commercial plan coverage and access for drugs used to treat Multiple Sclerosis (MS). Specifically, Avalere\u2019s analysis aimed to evaluate trends in formulary coverage and access to MS therapies across Part D and commercial plans to assess how formulary coverage has changed over time and how it varies based on plan type, approval year, availability of a generic alternative, and drug efficacy. The analysis leveraged a study<\/a> where the efficacy of MS drug therapies was evaluated based on the drug\u2019s ability to reduce annualized relapse rates in Phase III clinical trials.<\/p>\n

Avalere categorized drugs based on the following:<\/p>\n