PSY81 - Do Us Payers Consider Cost-Effectiveness when Defining Prescription Benefits? A Study of Targeted Therapies for Rheumatoid Arthritis and Moderate-To-Severe Psoriasis

Abstract

To evaluate the influence of cost-effectiveness analysis (CEA) in payers’ definition of prescription benefits for targeted therapies to treat rheumatoid arthritis (RA) and moderate-to-severe psoriasis. CEA of targeted therapies was obtained from evidence reports by ICER (Institute for Clinical and Economic Review) and compared with prescription benefits offered by the ten largest US payer groups. Results When combined with conventional DMARDs (cDMARDs), the targeted therapies rituximab, abatacept, tocilizumab, certolizumab, golimumab and infliximab were all considered less costly and more effective than adalimumab combined with cDMARDs in the treatment of RA on a lifetime horizon; however, adalimumab still has the highest coverage profile, being preferred by 70% of US health plans. Xeljanz was considered even costlier and less effective than adalimumab, but appears to be preferred over the latter by Express Scripts and Kaiser Foundation. When compared to cDMARDs alone, sub-cutaneous tocilizumab demonstrated the highest probability of being cost-effective (27%) at a willingness-to-pay of $150,000/QALY. However, it is one of the least preferred across health plans. Interestingly, five out of ten payers have lower coverage or greater restrictions for infliximab-dyyb (biosimilar) than for infliximab, but Express Scripts actually shows preference for the biosimilar product. Regarding moderate-to-severe psoriasis, eight targeted therapies have been considered cost-effective against DMARDs at a 10-year time horizon. Apremilast, which had the lowest ICER ($89,843/QALY) is one of the most preferred agents across health plans. However, ustekinumab, which presented the highest ICER ($129,904/QALY), has very similar coverage to apremilast. Cost-effectiveness does not appear to be a key criterion for US payers when defining prescription benefits for the treatment of RA and moderate-to-severe psoriasis with targeted anti-rheumatic drugs, suggesting that cost-effectiveness does not necessarily translate into affordability and the actual purchase pricing and negotiated rebates play a more important role in defining prescription benefits.