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Pharmaceutical Executive


Cost Conundrum


Abbott’s interactive ‘virtual doctor’ feature lets website visitors practice the conversation they may have at the doctor’s office.
Even for patients with insurance, access to Humira requires a "very rigorous" prior authorization process, says Stewart. Before paying for the drug, insurance companies have to verify the patient is authorized and has the corresponding benefit, and that the indication is on-label—and that can take time. Given the value of each new Humira patient, Abbott has endeavored to expedite the process, and make it easier for patients to get access to the drug. "We have a reimbursement hub that enables doctors and patients to call and find out if a given insurance benefit will cover Humira," and that gives patients an idea about what their copay might be, says Stewart. Copays can be substantial, particularly with plans that use co-insurance for expensive biologics; with co-insurance, the patient pays a percentage of the total cost, rather than a set rate. Private insurance plans have increasingly moved from copays to co-insurance to lower costs—Stewart estimates that 20 percent to 25 percent of commercial plans use co-insurance—and that means patients are on the hook for a bigger chunk of the cost.


In 2011, Abbott spoke directly to consumers "like never before," while still maintaining communication with physicians.
To help patients hurdle the cost barrier, Abbott created the Humira Protection Plan, which offers financial assistance to those who need it. If a patient is employed and has a prescription drug benefit, the company "can reduce your copay to $5 month," according to the program website. Unemployed and/or uninsured patients may also be able to get the drug at no cost, through the Abbott Patient Assistance Foundation, assuming they meet the requirements. The Foundation provides assistance for Abbott products only, but since methotrexate has been shown to improve the efficacy of Humira, other independent copay foundations can provide additional assistance. By law, Abbott can't assist patients under Medicare Part D. Stewart says Humira's market share under classic Part D is lower than its share in the commercial insurance market. "We've hypothesized that a lot of that is due to the varying incentives of a medically reimbursed infusion," which is covered under Medicare Part B, and many Part D patients "often have high co-pays initially, and then are very likely to hit the donut hole," says Stewart. The financial incentives for physicians around medically reimbursed agents, particularly infusion versus subcutaneous injection, and the corresponding Medicare benefits, contain "a lot of complexities that patients have to navigate," says Stewart.

Regarding financial assistance, Ladd says most of the available programs, including Abbott's, "really help in cases of need ... some of them are very generous." But financial assistance programs can only be used for approved, on-label conditions. Ladd says a lot of patients get off-label scrips for anti-TNFs—for example, an autoimmune eye disease that can cause blindness—but in that case, Abbott can't provide the drug or assist with the cost, and insurance companies won't cover it either.


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