What is a drug rebate?
Drug rebates are discounts paid by drug manufacturers to health plans and pharmacy benefit managers (PBMs) who purchase their drug. Rebates are determined by terms set forth in contracts which are typically negotiated annually between pharma companies and payers. The most common type of rebate is volume-based, in which the rebate increases as the PBM or plan pays for more of the same drug.
Negotiations between a payer and a pharma company for specific rebate levels are determined through a dynamic process, particularly in markets that are competitive (having multiple therapeutic options at a particular place in therapy).
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What is a Market Access Account Executive?
A market access account executive is a field-based member of the market access team who meets with payers to discuss potential drug coverage. Each account executive calls on a specific set of payers and works closely with medical outcomes liaisons to meet the needs of those payers. Specifically, an account executive is responsible for aspects around contract negotiations with the plan in coordination with internal pricing and contracting teams and payer marketing.
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What are Health Outcomes Liaisons?
Health Outcomes Liaisons are field-based medical professionals who call on payer customers including managed care, pharmacy benefit managers (PBMs), health plans, integrated delivery networks (IDNs), and other population-level decision-makers.
Similar to medical science liaisons, outcomes liaisons are medically trained professionals often with advanced degrees. They can speak to off-label material in a similar manner to MSLs. Instead of providers, however, they are addressing questions and providing information to payers.
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What is Health Technology Assessment (HTA)?
Health technology assessment is the systematic evaluation of medical technologies for cost-effectiveness. It is often a necessary part of gaining access through government payers in Western countries outside of the US. The National Institute for Health and Care Excellence (NICE) in the UK is one of the more prominent organizations and decides drugs what the UK National Health Service will pay for based on whether or not they are deemed to be cost-effective.
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What is a Specialty Drug?
A specialty drug is one which is of very high cost or has special counseling requirements. Payers will typically designate certain drugs in their specialty tier and will only reimburse pharmacies they recognize as specialty pharmacies to dispense them. Medicare defines any drug with a monthly cost greater than $670 as specialty. Commercial insurance usually cuts off specialty designation at similar dollar amounts. Drugs which have strict requirements in terms of patient counseling or monitoring will also often be designated into specialty tiers.
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What is Reference Pricing?
Reference Based Pricing as it pertains to pharmaceutical drug pricing is when governments or payers restrict what prices they will may for a drug based on benchmarks such as prices paid in other countries. Usually, countries that use reference pricing compare proposals from a pharma company to prices in a basket of other countries and use that to limit what they will pay. The benchmark can be set at the lowest price in the basket or somewhere along the distribution (eg at a certain percentile).
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What is Real World Evidence?
Real world evidence (RWE) refers to evidence from data sources with greater generalizability than that which is typically gained from phase I-III clinical trials. The most common form of RWE is observational studies of retrospective data such as electronic health records (EHR) or administrative claims data (such as Truven Marketscan or Optum Clinformatics). Randomized forms of RWE include pragmatic clinical trials which typically have more relaxed inclusion and exclusion criteria compared to registration trials and thus include a more heterogeneous population.
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What are copay cards for prescription drugs?
Copay cards are a form of assistance that pharmaceutical companies offer patients in order to reduce their burden of out-of-pocket costs including copays, coinsurance, and deductibles in the United States. The discount or terms of these cards can vary, but usually cover a significant portion of the out-of-pocket expense for a given drug. They are most commonly usable for patients with commercial (non-government) insurance.
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Health Economics and Outcomes Research is the functional area focused around economic modelling for payer stakeholders (including HTA bodies and insurance companies) and real world evidence generation. It usually sits within the Medical Affairs or Global Market Access organization and is very scientifically-driven, with most work being done with the aim of having scientific dialogue with technical experts or for publication in peer-reviewed journals.
What is Health Economics?
The health economics component is often centered around cost-effectiveness modeling, especially in global organizations.
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What is Market Access?
Market Access is the functional area focused on ensuring that third party payers including governments and insurance companies are covering or paying for drugs so that patient can actually get them once a provider writes a prescription. It involves setting pricing for a drug, negotiation of contracts and utilization management, and payer marketing. Market Access is also the in-house expert on the payer landscape and may advise on commercial strategy including life cycle management and where to play in the market.
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