艾昆纬-处方集控制对五个慢性病治疗领域商业保险患者的影响（英）

White PaperThe Impact of Formulary Controls on Commercially Insured Patients in Five Chronic Therapeutic AreasRAHEL EHRENBERG, Principal, U.S. Market Access Strategy Consulting, IQVIAKRISTEN COPLEY, Consultant, U.S. Market Access Strategy Consulting, IQVIASIDDHANT GUPTE, Assoc. Consultant, U.S. Market Access Strategy Consulting, IQVIATable of contentsIntroduction 1Key takeaways 1Formulary controls 2Time and effort to overcome formulary controls 4Impact of formulary control on patient treatment 5Discussion 6Disclaimer 8Acknowledgements 8Key terminology 8About the data 8About the authors 9 iqvia.com | 1IntroductionCommercial payers leverage formularies to manage prescription utilization and costs by employing control measures such as prior authorizations, step therapy, and formulary exclusions. These payer restrictions have increased over the past decade and can result in patients’ prescriptions being rejected at the pharmacy counter. Experiencing a rejection at the pharmacy can add layers of complexity to a patient’s treatment journey and can also lead to delayed or forgone care.To demonstrate how commercial payer controls may impact patients attempting to initiate treatment, we conducted in-depth, longitudinal analyses of payer rejections occurring from January 2020 through July 2024 across five chronic Therapeutic Areas (TAs) — pulmonary arterial hypertension (PAH), osteoporosis, multiple sclerosis (MS), immunology, and migraine. Top brands, as determined by market share, across the selected TAs were selected for analysis. Patients were tracked for one year following an initial attempt to fill a prescription. For those who faced a payer rejection and successfully overcame it, the time to coverage and number of attempts needed to overcome the rejection were quantified. For those KEY TAKEAWAYS• Over 75% of commercially insured patients were initially denied coverage when attempting to fill a new prescription across the five therapeutic areas analyzed. More than 90% of patients were initially denied in four of the five therapeutic areas.• Patients who were initially denied but successfully appealed a payer rejection experienced average coverage delays exceeding three to five weeks, depending on therapeutic area. Between 17% and 31% of patients experienced a delay of more than five weeks.• Patients had to overcome an average of two to four rejections before obtaining approval, although some had to navigate through 11 or more rejections. • Between 64% and 82% of patients who did not overcome their initial payer rejection within a year failed to initiate any new treatment in the same therapeutic area.unable to overcome a rejection — meaning the patient did not ultimately receive their prescribed medicine — we tracked the proportion of patients who started an alternative therapy and the proportion who failed to initiate a new treatment in that therapeutic area. This report sheds light on the time and effort required for commercially insured pat