JRoon71
10 hours ago
RMB, don't really know that.
I get the impression that each region has their own overall budget that they have to stick to (not a per-drug limit). But I sort of doubt they would cut off scripts in any way if they exceed their budget.
At worse, they would re-negotiate when the contract is up, but I don't really know that process. There's definitely information online about it, I just haven't dug that deep yet.
I think the biggest hurdle was getting AIFA approval, and now hopefully France is next, possibly in 2025, then China in 2026, and hopefully all the other countries currently approved start selling scripts ASAP.
JRoon71
1 day ago
Sleven, based on what I read, they would use the AIFA-approved script criteria to establish an estimated population, which translates to an estimated total national cost.
So they look at the estimated population of 250K people, take a % that they estimate will have scripts written (say it's 10%), and then apply the monthly reimbursement rate (EU 170).
Then they divide that up among the regions.
So all told, let's say they project 25,000 scripts to be written, that would be 25,000 x 170 x 12 = EU 51M
Then that 51M gets allocated among the regions, based on population.
At least that's what I took from the various sources I read.
rosemountbomber
1 day ago
Yes, there seems to be an endless supply of formularies that CVS Caremark pushes out. I checked out a few online and the vast majority do not cover Vascepa at all, but the Medicare plans usually do.
Found this on one of their websites explaining how they operate:
An effective formulary strategy is the foundation of cost containment. Our approach prioritizes coverage for clinically appropriate, cost-effective medications for members while ensuring low net cost for our clients. And as of January 1, 2025, we’re improving access further – without impacting client financials – with more inclusions to our Standard Control Formulary than last year. Hyperinflation management – removing drugs with hyperinflated prices from our formularies, that have readily available, clinically appropriate, and cost-effective alternatives – is embedded within our managed template formularies to prevent wasteful spend. In a constantly evolving pharmaceutical environment, biosimilars represent one of the biggest opportunities for reducing drug costs for payors and patients. Up to eight biosimilars for Stelara® are expected to launch in 2025, representing a significant cost reduction opportunity.
With each new entrant, we will evaluate it consistently within our formulary process, with a review of clinical, economic, and market factors, to ensure we get to the optimal outcome for our clients.
https://business.caremark.com/insights/2024/2025-cvs-caremark-formulary-updates.html
JRoon71
1 day ago
Ah, got it. Yeah, that doesn't really address that. It looks like pricing can vary a bit by region (I assume it would only be lower). I can't find anything on adjusting patient population, but based on everything I've read so far, it would seem illogical for a region to EXPAND the patient population. Everything seems to point to regions contracting what they are willing to pay for, versus the AIFA approval.
Yes, in Italy, individual regions can choose different reimbursement rates for drugs compared to the national rates set by AIFA (Agenzia Italiana del Farmaco), meaning that even if a drug is approved for reimbursement at a certain price at the national level, each region can decide to reimburse it at a slightly different rate based on their own local considerations; this can lead to variations in patient access to medications across the country depending on where they live.
Potential challenges:
This system can create complexities for pharmaceutical companies navigating market access in Italy, as they may need to negotiate different pricing agreements with each region.
Currently, only three regions (Val d’Aosta, Calabria, Liguria) and the autonomous province of Trento adopt the National PHT without any local adaptation.
JRoon71
1 day ago
Well this sounds like quite the laborious process...
while most drugs are generally eligible for reimbursement in Italy through the national health service, the specific drugs covered and reimbursement levels can vary depending on the region, meaning not all drugs are reimbursed equally across all regions in Italy; each region has its own process for evaluating and including drugs on their reimbursement list, sometimes leading to disparities in access.
Regional variations:
Although AIFA sets the initial reimbursement status, individual regions can further decide which drugs to include on their local reimbursement lists and at what level of coverage.
This seems to explain it pretty explicitly:
Reimbursement for drugs is often a barrier to market access; is this true in Italy today?
Yes, absolutely. The challenge is that the there are two reimbursement processes in Italy – national reimbursement as part of AIFA’s approval, and the inclusion of new medicines in the regional list of drugs. So, a company can successfully go through the process of evaluation and approval with AIFA, including agreement for reimbursement at a specific price. But then you have to get market access at a regional level, which is not only a new battle but also a more complicated one. Italy has 20 regions, and most have their own approach. Plus, the regions each go through their own process of evaluating a drug. This decision is misguided because the AIFA evaluation is extremely thorough, looking at three points: unmet medical needs, added therapeutic value, and quality of clinical trial data. This is a unique approach – many other HTAs do not look at data quality in-depth. So the regional evaluation is pointless, and only serves to delay patient access to the drug. The AIFA evaluation takes 12 – 15 months, and then the regional process can take up to 15 months. So sometimes, it could be up to 30 months before a drug can reach the market, depending on the region.
JRoon71
1 day ago
So it looks like the Italy rollout might be more analogous to how it went in Canada, versus, say Spain.
I also found this:
In Italy, "regional access for drugs" refers to the process where each of the country's 20 regions independently evaluates and decides whether to include a drug within their local healthcare system, allowing patients within that region access to the medication, even after it has received national approval from the Italian Medicines Agency (AIFA) at a national level; this means access to a drug can vary significantly depending on which region you live in.
The Italian National Health Service (NHS) is decentralized and organized on three different levels (national, regional, local). The Italian Medicine Agency (AIFA) is responsible for drug evaluation and pricing and reimbursement (P&R) decisions, while the 19 regions and 2 autonomous provinces (APs) have autonomy and direct responsibilities for planning healthcare services and allocating financial resources and can autonomously regulate the market access process within their territories.
After national marketing authorization and definition of conditions of reimbursement by AIFA, drugs need to undergo further regional and local steps to be acquired by hospitals and/or local health units in order to be available to patients. These steps may differ across regions and, in some cases, even across districts within the same region. In this context, drugs’ time to regional access, defined as the time from AIFA Pricing and Reimbursement (P&R) resolution publication in the Italian Official Journal to first regional sales, is highly variable among different regions.