Plans also employ interventions to influence product
selection, such as patient cost sharing differentials
(see Figure 5). Few plans use step therapy, a
traditional utilization management tactic, to mandate
use of a specific protease inhibitor, recognizing
the necessity of providing treatment choice due
to variations in side effects and individual patient
characteristics (e.g., risk profile for resistance,
duration of treatment length tolerance). However,
many plans implement step edits for pegylated
interferons due to long-standing perceptions of
interchangeability, setting a precedent for future
management in this category.
Increasing Use of Payer
Interventions Will Create Challenges
for Broad Patient Access to
Therapies
FDA approval of additional oral agents and CDC
efforts to identify patients will expand utilization and
increase plan expenditures. Growing cost pressures
will influence plans to modify current approaches to
managing hepatitis C agents by 2016.
Following the entrance of multiple interferon-free
regimens, most plans will consider advantaging
one or more through lower cost sharing and step
edits, essentially restricting patient access to select
regimens (see Figure 6). In similar high-cost specialty
drug categories with multiple poorly differentiated
agents within classes (e.g., multiple sclerosis,
rheumatoid arthritis), plans often mandate trials of a
preferred brand. Plans perceive that a highly effective
interferon-free regimen with a short treatment
duration will adequately address critical unmet
needs.
Coverage policies for off-label use of first-generation
PIs have been relatively lenient due to the lack of
treatment alternatives for patients failing the standard
of care. However, potential doubling of price and
strong demand for experimental regimens are likely
to prompt policies that deny off-label use of future
regimens in patient types where efficacious and
tolerable treatment options already exist. In addition,
most plans will implement treatment pathways
that drive utilization to specific products according
to genotype, including subgenotype, and prior
treatment response. Plan management efforts seek
to optimize outcomes and minimize therapy waste.
Payers Will Seek Increased
Collaboration with Specialty
Pharmacie