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Eylea, Lucentis Equally Likely to Be Covered on Commercial and Medicare Advantage Plans for Wet AMD

Pricing will be key to formulary acceptance of Fovista and abicipar pegol

Aflibercept (Eylea, Regeneron), the most recently launched antivascular endothelial growth factor (VEGF) agent for wet age-related macular degeneration (AMD), is as likely to be covered on commercial and Medicare Advantage plans as ranibizumab (Lucentis, Genentech), the standard of care for wet AMD, according to the health care research firm Decision Resources Group.

Although surveyed managed care organization (MCO) directors did not identify a clear clinical or economic advantage with aflibercept, the drug is slightly more likely than ranibizumab to be listed on tier 1 or 2 on Medicare Advantage plans, the primary private insurance type for the wet AMD patient population; this may facilitate access for patients covered by these plans.

Assuming that a biosimilar ranibizumab demonstrates efficacy comparable with that of ranibizumab in studies of patients with wet AMD and is priced at a 20% discount, most of the surveyed payers would reimburse the agent on their plans within 1 year of availability. Some MCOs were likely to place biosimilar ranibizumab on more-favorable formulary tiers than ranibizumab and aflibercept. Given that surveyed retinal specialists also appeared receptive to incorporating biosimilar ranibizumab into their practices, the use of all of the major anti-VEGF agents will likely be affected if a biosimilar ranibizumab launches.

“Developers of new wet AMD therapies may face challenges when drug attributes that drive physician prescribing differ from those that drive payers’ formulary-inclusion decisions,” said analyst Emma McFadden, PhD. “As an example, while less frequent dosing than current anti-VEGF agents was the top developmental goal for surveyed retinal specialists, relatively few payers selected achievement of this goal as likely to lead to preferred tier status for a new therapy.”

In the survey, the demonstration of superior head-to-head efficacy compared with standard of care — especially a greater effect on visual acuity — represented one of the most influential routes for new wet AMD therapies to gain formulary inclusion or placement and preferred tier status. This finding bodes well for emerging agents, specifically the anti–platelet-derived growth factor (anti-PDGF) agent Fovista (Ophthotech) and the aminosterol compound Squalamine (Ohr Pharmaceutical); early data suggest these treatments improve visual acuity compared with ranibizumab.

“Emerging wet AMD therapies including Fovista and abicipar pegol [Allergan/Molecular Partners] will need to be priced competitively to Eylea and Lucentis in order to garner favorable tier placement,” McFadden said. “Indeed, payers were much more likely to exclude or NDC-block these therapies as the hypothetical annual cost increased, indicating that they perceive these agents as being valuable treatment options for wet AMD up to a certain price point, after which their clinical advantages do not outweigh the additional cost.”

Source: Decision Resources Group; September 18, 2014.

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