Case Study 5 – Payer Influencers and Drug List Positioning

Identifying the Issue
A DK Pierce client manufactures a physician-administered oncology supportive care drug. DK Pierce informed the client that their drug was included in a comparative effectiveness review study for all drugs encompassed under the drug class. The final report generated by the review resulted in coverage implications for the drug class and ultimately affected the formulary position of our client’s product.
 
The Role of DK Pierce & Associates
In addition to monitoring payer and provider communications, DK Pierce also monitors key third party entities that supply information and assessments to payers for use in their drug coverage and utilization management decisions. This information is then used to define payer formularies and Medicaid Preferred Drug Lists (PDLs). As part of our surveillance services, we notified the client of the comparative effectiveness review and how it related to their product’s drug class. DK Pierce was concerned about the potential impact the report might have on our client’s drug. We understood that these reports affect the drug classes that Medicaid agencies’ Pharmacy and Therapeutics (P&T) Committees and Drug Utilization Review (DUR) Boards choose to review when determining formulary and PDL placement.

For the next several months, DK Pierce monitored all Medicaid P&T Committee and DUR Board meeting agendas and informed the client each time a review was scheduled for their product’s drug class. After each meeting, DK Pierce monitored the agencies’ Preferred Drug List to track how the drug class reviews translated into product positioning.

Demonstrated Outcomes
Keeping the client informed about each Medicaid meeting pertinent to their drug class allowed our client ample time to submit dossiers with supportive clinical data to the agencies. More importantly, the client now had the lead time to attend critical meetings and capitalize on the rare opportunity to present their clinical coverage rationale to the reviewing committee.

Prior to the publication of this comparative effectiveness review report, this class of drugs was seldom included on Medicaid Preferred Drug Lists. As a result of the report, the drug class now appears on about half of all Medicaid PDLs across the U.S. DK Pierce initially created a benchmark report to provide our client with a coverage “snapshot” of their drug and competitive drugs. We kept the client informed by tracking and reporting any coverage evolution. This allowed our client to create strategies to optimize patient access where necessary.