Case Study: Managed Care


With a promising drug for autoimmune hepatitis C (AIH) under development, a large pharmaceutical company wanted to better understand the market space, mainly as it pertained to managed care. Current drugs for AIH were generally used to delay a liver transplant. The potential new drug was showing evidence that it might eliminate the need for a transplant altogether—making it a new option for patients. As a result, the company wanted to understand what managed care organizations may expect – and accept – as the cost of a new, branded product, particularly in a marketplace dominated by generics.

Business Question

Where is autoimmune hepatitis C (AIH) on the radar of managed care companies and what factors will affect tier placement and reimbursement cost?

The Answers & Insights Approach

Healthcare is complicated. That is especially so when it comes to the coverage, reimbursement and payment. But, with Answers & Insight’s knowledge of managed care (as well as its understanding of the therapeutic category), it was able to go directly to the decision-makers of managed care plans to help answer the key business question.

Using its proprietary database of more than 500,000 health care professionals, Answers & Insights identified members of Pharmacy & Therapeutics Committees from key managed care plans in the U.S. Because they are involved in new drug evaluations for health plans, P&T Committees influence decisions about coverage, benefit design and pricing of drug therapies.

Answers & Insights scheduled IDIs, or in-depth interviews, with managed care professionals to gather qualitative information on:

  • Estimated of cost of disease beyond pharmaceutical costs
  • Issues treating these patients
  • Satisfaction with current products
  • Unmet needs with treatment
  • Expectations of new AIH product and how may that could impact formulary status

Additionally, A&I share the product profile with each of the managed care administrators to gather their input on:

  • General reactions to the potential drug therapy, including pros and cons
  • Strengths of product, compared to current therapies
  • Level of priority a new AIH drug would be to their plan
  • Factors that influence the decision process for tier specification
  • Recommended tier level
  • Impact of cost of branded products on tier decision
  • Estimated pricing
  • Barriers that may lead to unfavorable formulary status
  • Determination of which patients would be approved for coverage of this drug (based on stage of disease)

Customer Benefit

With this knowledge of the market space in hand before the product was even approved or launched, the pharmaceutical company was able to understand the type of patient they could target with physicians, as well as what the managed care market was likely to allow when it came to tiering, restrictions and, ultimately, patient access.