RxMedAccess

Building out a robust payer account team ahead of launch can be a daunting task. This generally requires: 1?? Efficient deployment of national/regional account directors/managers coverage various states/US regions + 2?? Payer channel segmentation (which may vary by state) + 3?? Payer account tiering and refinement (based on total covered lives, varying by channel book of business) ??If all tactical steps are done correctly, then the real work begins: synthesizing a compelling payer engagement strategy, usually centered around education covering high unmet needs or clinical value propositions. We are curious to hear from you:

As deals begin to heat up at J.P. Morgan’s 43rd Annual Healthcare Conference in San Francisco (Johnson & Johnson just acquired Intra-Cellular Therapies for ~$15 billion), achieving positive ROI is paramount given big Pharma generally invests in “pipeline potential” — contingent on FDA approval. However, securing regulatory approval is only step 1 to successfully launching a product — step 2 involves a multi-faceted commercial launch strategy, with market access typically front and center. (for better or for worse) Payer coverage is becoming increasingly vital for commercial viability. Due to the vast # of approvals in the same TA today, payers will tightly manage and must cover said product to unlock access, and ultimately reimbursement. Without product coverage, M&A deals may be dollars going down the drain at the expense of shareholders and investors. At RxMedAccess, we ensure your commercial team is equipped with a toolbox of payer insights, so you can make informed access decisions to drive launch success. https://lnkd.in/eXm9SYt6 #mergersandacquistions, #jpmorgan #marketaccess

As 2025 kicks off, Pharmacy & Therapeutics (P&T) and Value & Access Committees (VAC) across thousands of US payers covering Commercial, Medicare (FFS + Adv), Medicaid (Managed + State), etc. books of business likely updated their respective pharmacy benefit formularies and/or medical policies in high cost or clinical unmet need therapeutic areas (TAs). ?? While changes in coverage generally occurs on a quarterly (or ad-hoc) basis, our payer access dashboards observes significant step through coverage or related prior authorization criteria changes at the start of each fiscal year (due to budgetary and similar reasons alike). ?? Stay up to date on how this may impact your market access/GTM commercial launch strategy for you pipeline or portfolio products, with our machine learning payer intelligence tools at RxMedAccess. ?? Learn more today how we can help ensure optimal patient access and reimbursement: https://lnkd.in/eXm9SYt6

As of January 1st 2025, Independence Blue Cross will no longer cover (and consequently reimburse) drugs, biologics, or gene therapies that receive accelerated approval for a period of 18 months. ? Therapies will be excluded if: 1?? Accelerated approval was based on a surrogate endpoint. 2?? The drug does not have a final, standard, or traditional FDA approval. 3?? The FDA indicates that a confirmatory trial is necessary to demonstrate clinical benefits. This marks an unprecedented policy statement (no pun intended) by a regional Commercial payer in an effort to presumably control costs, and only pay for therapeutics with clinically meaningful safety and efficacy data. Will this bold move open the flood gates for larger regional / national Commercial and Medicare Adv insurers to restrict access for products without standard regulatory approval? ? Only time will tell. Policy link: https://lnkd.in/eqZg9CEH Follow us for more payer coverage and policy alerts. #fda #policy #payercoverage #acceleratedapprovals #regulatoryaffairs #marketaccess FDA AHIP

No surprise here: The top 2 health plans with the largest % of "extremely high" and "high" PA burden for practices and patients, are also coincidentally the largest (top 2) Medicare Advantage providers by books of business - United Healthcare and Humana. Source: American Medical Association Insightful post Adam Fein

1?? Fun Fact: Did you know in 2024, Medicare Advantage (MA) grew to 54% of all Medicare lives, surpassing Traditional Medicare (i.e., FFS) channel in 2023? 2?? Market Access Implications: In many cases, since MA plans have limited provider networks, they generally apply cost management tools such as prior authorization (PAs), ultimately delaying access to drug therapies, while Traditional Medicare normally does not. 3?? Solution: At RxMedAccess we evaluate how the largest MA providers in the country (UnitedHealth Group, Humana, and Blue Cross Blue Shield plans, etc.) manage therapeutic drug classes among medical and pharmacy benefits, and what that means for your payer engagement strategy. 4?? Learn more today: www.rxmedaccess.com Source: https://lnkd.in/gNZ-m_gh

?? Did you know in wAMD, Avastin is covered 1st line across all major Medicare Advantage and Commercial payers, with access to Eylea and Vabysmo requiring step edits in up 60% of covered lives? ?? With newer entrants entering the wAMD space (i.e., biosimilars), payers will continue tightly managing this therapeutic area, making it challenging to gain access immediately post launch. ? With RxMedAccess suite of payer intelligence tools, you can strategically navigate payer utilization management hurdles to improve your assets line of therapy at time of launch. Learn more on how we can support your payer access gaps today: https://lnkd.in/eXm9SYt6 #payercoverage #marketaccess #payeraccess #steptherapy #utilizationmanagement

?? Embarking on your payer engagement strategy can be difficult without combing through hundreds of medical policies and drug formularies to understand Step Therapy (ST) or Prior Authorization (PA) utilization management criteria for your therapeutic area(s). ?? What’s more tedious is combing through this data semi-annually, and in many cases quarterly, due to constant step edit criteria changes, particularly in a crowded therapeutic areas, i.e., oncology or ophthalmology. ?? With RxMedAccess user-friendly payer insights & analytics tool, you can quickly and accurately evaluate your assets coverage access landscape by product basket, payer channel(s), and/or plan(s). ? Learn more today at: www.rxmedaccess.com #payeraccess #patientaccess #payercoverage #medicalpolicy

A recent Medpage article highlights the use of prior authorizations (PAs) in the Medicare Advantage (MA) program continues to increase, according to a report from KFF — with more than 46 million PAs submitted in 2022. What is more concerning is that not all PAs are created equal for the same pharmaceutical product, or service, “While all MA insurers require prior authorization for at least some services, there is variation across insurers and plans in the specific services subject to these requirements," the researchers wrote. As a result, market access teams navigating complex and inconsistent utilization management (UM) hurdles may become increasingly burdensome, as higher annual cost medical and pharmacy benefit products continue to hit the market. RxMedAccess payer coverage analyzer tools allows you to seamlessly identify variations among such policies and formularies, eliminating the lift of distilling complex UM criteria’s across payers — equipping your team with access data points to inform a robust payer engagement strategy. Learn more how today at: www.rxmedaccess.com Source: https://lnkd.in/dBtF3dK7

Want to learn how RxMedAccess can enable your market access team to address your payer coverage business needs? Click below for a sneak peak of one of our core products to learn more. https://lnkd.in/ekasg2GG