Each health insurance plan has a formulary – a list of the prescription drugs for which they will pay. Most formularies have a tiering system in which the patient’s copay increases for each tier.
Historically, generics are placed in Tier 1, “preferred brands” in Tier 2, and “non-preferred brands” in Tier 3. More recently, a fourth tier was added for specialty drugs. Then, some plans introduced a tier between 1 and 2, for “non-preferred generics.” But in recent years, payers have introduced a sixth tier.
A six-tier formulary often follows this order:
- Preferred generic
- Non-preferred generic
- Preferred brand
- Non-preferred brand
- Preferred specialty
- Non-preferred specialty
The goal is to steer patients toward preferred products – originally a practice for standard prescription brands, but now applicable for generic and specialty drugs. Often, instead of a copay, co-insurance is required for non-preferred drugs, and the patient is responsible for paying what can be a sizeable percentage of the price.
Increasing tiering requires a paradigm shift for affected brands. This is most important now for specialty drugs, such as biologics, oncolytics, or treatments for rare diseases, for whom this can be an enormous change.
HCPs and patients need your help more than ever. As formularies increase in complexity, brands can provide more value than ever by giving actionable information about coverage and reimbursement to HCPs and patients. Rep tools can achieve this, coupled with messaging and training that ensures the information is conveyed effectively. Patients also need help, which can be provided via brand and patient-support websites, CRM campaigns, and social media.
Market access has never been simple, and it’s only getting more complex. From co-insurance to copay accumulators, the “donut hole” to the six-tier formulary, changes to reimbursement will continue. It’s vital to adapt quickly in order to position your brand in this evolving market.
For case studies on patient and provider tools that have helped brands hurdle market-access issues, contact your Intouch team or firstname.lastname@example.org.