PBMs的垂直附属药房如何为肿瘤学和自身免疫患者塑造获取途径

How PBMs’ Vertically AffiliatedPharmacies Shape AccessPathways for Oncology andAutoimmune Patients 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 Introduction1Key takeaways1Formulary controls2Time and effort to overcome formulary controls3Discussion5Disclaimer6Acknowledgements6Key terminology6About the data6About the authors7 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/ormail pharmacies as part of their business. While PBM-owned, vertically affiliatedpharmacies are positioned as a means to reduce costs, they can also createbarriers to access, resulting in delays as patients’ claims are transferred throughthe system to pharmacies affiliated with their PBM. 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 theseconditions have previously been analyzed to show that despite the need for and efficacy of such medicines, utilizationmanagement tactics have delayed treatment.1 Key takeaways •Patients who submitted prescriptions for immunology and oral oncology medicines at non-affiliated pharmacieswere more likely to encounter rejections than patients who initially attempted to fill at their PBMs’ affiliatedpharmacies. •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 daysversus 16 days for immunology, and 17 versus 10 days for oral oncology. •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 and22 days for oral oncology. •Regardless of pharmacy affiliation, most patients who were initially rejected but ultimately gained approval for theirimmunology and oral oncology medicines encountered multiple rejections before gaining approval. those filling at non-affiliated pharmacies, 42% of oraloncology patients and 33% of immunology patientswere approved at their original pharmacy after an initialrejection, and another 14% and 20% gained approvalwith a switch to an affiliated pharmacy. 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 oncologyand 92% of immunology patients attempting to fill a newbranded medicine at non-affiliated pharmacies wereinitially rejected, whereas patients attempting to fill ataffiliated pharmacies were initially rejected less often(58% in oncology, 71% immunology). 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 pharmacieswere never able to get approved for their treatmentwithin a year. The disparity in cohorts was morepronounced in oral oncology, where 30% of patientsattempting to initiate treatment at non affiliatedpharmacies were never approved, almost twice the finalrejection rate of 16% at affiliated pharmacies. Over time, some patients were able to work throughtheir rejections, potentially by submitting requireddocumentation, doing more tests, or switchingfrom non-affiliated to affiliated pharmacies. Among rejected again at an alternative pharmacy, andonly secured approval at a third or later site (IQVIAanalysis, data not shown). This suggests that switchingpharmacies can create uncertainty about whichpharmacies are preferred and, at minimum, introduceadditional hurdles for patients. Time and effort to overcomeformulary controls 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 after10 days, compared to 32 and 17 days at non-affiliatedpharmacies, respectively. Patients who switched toaffiliated pharmacies after they were initially rejectedat non-affiliated pharmacies faced the longest