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Maximizing Access in an Evolving Policy and Payer Landscape

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Manufacturers currently face an almost-unprecedented level of uncertainty in developing contracting strategies for the coming plan years. Avalere’s combination of policy and commercialization expertise, paired with its data capabilities, allow us to support life sciences companies understand this challenging landscape to ensure access to innovative therapies for their patients.

The Landscape

Congress is contemplating a potential overhaul of the Medicare Part D benefit structure and a host of new measures to reduce drug price increases and limit beneficiary out-of-pocket liability, while the administration weighs the potential for additional executive action to achieve these ends. Meanwhile, markets have begun to proactively adjust to this shifting landscape by offering point-of-sale rebates to enrollees (e.g., CVS’s SilverSript Allure Medicare Part D plans) and implementing advanced formulary designs (e.g., indication-based formularies). The significance of these policy- and market-based changes introduce the need for manufacturers to take a meticulous approach to position their products in the Part D market and ensure patient access to the therapies in the coming years.

Take a Holistic Approach

Avalere has successfully supported life sciences clients address evolving policy and market challenges by utilizing its wide-range capabilities to develop short- and long-term strategies to drive patient access. Avalere combines its unparalleled expertise of healthcare policy, regulatory, and legislative issues with a deep understanding of the coverage and payment considerations that drive payer, provider, and patient decision-making. Leveraging both this policy and commercialization expertise, Avalere delivers integrated, end-to-end support to inform our life science clients’ broader market access strategies.

Collaborate with Nationally Recognized Healthcare Experts

Avalere continues to refine and deepen these capabilities, notably with the recent additions of Dr. Roy Beveridge and Mike Schneider to the firm. With this additional expertise in engaging payer, pharmacy benefit manager (PBM), and provider markets, Avalere is expanding its capabilities to support manufacturers as they develop formulary access strategies for Part D and commercial contracting in plan year 2021. Doing so will require a multi-phase approach, which includes:

  • Developing a deep understanding of the competitive landscape for the given therapeutic market, such as coverage, tier placement, associated cost-sharing, and utilization management of targeted products
  • Establishing the drivers for payer and PBM customer decision-making, such as enrollment characteristics, plan-PBM relationship dynamics, and customer capabilities (e.g., via vertical integration)
  • Outlining and modeling the impact that potential policy reforms–including ongoing and proposed legislative and executive branch activity–may have on contracting strategies

Utilize Our Robust Data Assets

Avalere is particularly well positioned to support life sciences companies address these diverse needs and is able to utilize its robust data capabilities to model how these insights and assumptions will inform a client’s customer engagement strategy for formulary access. Our breadth of commercial and Medicare claims data provides a unique line of sight into key utilization trends and can be queried via predictive analytics to inform formulary access strategies. Leveraging data from commercial, fee-for-service Medicare (100%), Medicare Part D (100%), Medicare Advantage, and managed Medicaid populations, Avalere has access to data with over 45 billion medical events, 271 million unique patients, and 531,000 clinical facilities in all 50 states (plus DC and Puerto Rico).

“Avalere’s data assets coupled with our unrivaled expertise in Part D plan formulary management provides clients with invaluable insights that will inform manufacturer contracting strategies,” says Dr. Roy Beveridge. In addition to practicing as a medical oncologist for over 20 years, Dr. Beveridge was most recently chief medical officer at Humana, the second largest Part D plan sponsor by enrollment in 2019.

“As competition continues to grow and health plans and PBMs advance their approaches to managing formularies, manufacturers must prepare for new opportunities as well as potential risks before coming to the negotiating table,” says Mike Schneider, former director of industry relations at CVS where he was responsible for trade strategy development, rebate negotiations, and contract execution for CVS Caremark’s Medicare Part D plans and those of its clients.

Partner with Avalere

Avalere’s unique depth and breadth of policy expertise, first-hand experience engaging payer and PBM customers, and robust and diverse data modeling capabilities allows us to support our life sciences clients navigate the evolving policy and market landscape to drive optimal patient and market access.

To learn more about Part D expertise, please contact Ben Shand.

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