PBM垂直附属药房如何为肿瘤和自身免疫病患者塑造获取途径

How PBMs’ Vertically AffiliatedPharmacies Shape Access RAHEL EHRENBERG,Principal, U.S. Market Access Strategy Consulting, IQVIAKRISTEN COPLEY,Consultant, U.S. Market Access Strategy Consulting, IQVIAPHILIPPA JOHNSON,Assoc. Consultant, U.S. Market Access Strategy Consulting, IQVIA Table of contents IntroductionKey takeawaysFormulary controls Introduction In the last several years, the pharmaceutical supply chain has seen continuedgrowth and verticalization within top healthcare companies, such that it is nowcommon practice for Pharmacy Benefit Managers (PBMs) to have retail and/or This paper measures the differences in access between patients who initiate treatment through their PBMs’ verticallyintegrated pharmacies, described here as affiliated pharmacies, compared to other non-affiliated pharmacies.We compare differences in access in both immunology and oral oncology markets, as patients affected by these Key takeaways •Patients who submitted prescriptions for immunology and oral oncology medicines at non-affiliated pharmacies •For patients who overcame payer rejections, those who ultimately filled prescriptions at non-affiliated pharmaciesexperienced longer delays to treatment than those who filled at affiliated pharmacies. Average delays were 32 days •Patients who switched from non-affiliated to affiliated pharmacies more often overcame payer rejections than thosewho did not switch, but they faced the longest delays prior to approval: an average of 42 days for immunology and •Regardless of pharmacy affiliation, most patients who were initially rejected but ultimately gained approval for their those filling at non-affiliated pharmacies, 42% of oraloncology patients and 33% of immunology patientswere approved at their original pharmacy after an initial Formulary controls Oral oncology and immunology drugs tend to be highlycontrolled on payer formularies. Patients who submittheir prescriptions to non-affiliated pharmacies faceinitial rejections — rejections associated with a firstattempt — at an even higher rate. 86% of oral oncology Though switching to affiliated pharmacies can facilitatepayer coverage for oncology and immunology, not allpatients managed to overcome their payer rejections.37% of immunology patients filling at affiliatedpharmacies and 39% filling at non-affiliated pharmacies Over time, some patients were able to work throughtheir rejections, potentially by submitting requireddocumentation, doing more tests, or switching rejected again at an alternative pharmacy, andonly secured approval at a third or later site (IQVIAanalysis, data not shown). This suggests that switching Time and effort to overcome After a rejection, patients filling prescriptions at affiliatedpharmacies in both immunology and oral oncologygained approval more quickly than those filling at non-affiliated pharmacies. On average, immunology patientsat affiliated pharmacies gained approval after 16 days,while oral oncology patients gained approval after Oral oncology patients encountered between 2 and 3rejections before getting approval, regardless of whetherthey filled at affiliated or non-affiliated pharmacies. Thedifference was more pronounced among immunologypatients, where those who switched from non-affiliatedto affiliated pharmacies encountered an average of1.2 more rejections before approval compared topatients who initiated therapy through an affiliated Transferring claims from non-affiliated to affiliatedpharmacies requires coordination and evenresubmission, often exposing patients to repeatedrejections and other challenges. Notably, switch patients treatment at non-affiliated pharmacies bearing adisproportionate share of these burdens. This trendplaces additional administrative and financial pressure onpatients who are already navigating complex treatment Discussion Patients filling prescriptions through non-affiliatedpharmacies faced more initial rejections and gainedapproval less quickly than those filling at affiliatedpharmacies. This creates a clear access gap. Vertically Importantly, this research highlights that coverage doesnot always equate to access — a distinction that becomesincreasingly critical as the population ages and grows,and the prevalence of chronic illness rises. Ensuring true Disclaimer Acknowledgements The authors would like to thank their IQVIA colleaguesfor supporting this research: in particular, Jack Wang, This report and the analyses used were sponsored by thePharmaceutical Research and Manufacturers of America Key terminology 1.Affiliated Pharmacy: A vertically integrated pharmacy affiliated with the patient’s PBM. 2.Non-Affiliated Pharmacy: A pharmacy not affiliated with the patient’s PBM. 3.Switch to Affiliated: Patients initially rejected at a non-affiliated pharmacy but approved at an affiliated pharmacy. 4.Not Covered Rejection: Patient does not receive approval as payer rejects the claim due to a formulary exclusion. 5.Prior Authorization/Step Re