US Government Drug Reimbursement


In the United States, the tasks of attaining formulary position and negotiating prices have become increasingly complex and competitive, especially in light of new guidelines under the Affordable Care Act (ACA). Use this report to understand how companies anticipate government payer needs, develop strong market access strategies, and manage payer relationships before and after product launches. Findings show how to prepare successfully for meetings with US government payers, how to create SOPs around reimbursement processes, and which functions to involve in price calculation processes. Benchmarks outline different structural approaches to US government reimbursement and show budgets for teams focused on this area.

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Top Reasons to Read This US Government Drug Reimbursement Report

Establish and Maintain Strong Payer Relationships to Win Optimal Formulary Position: Meaningful communication with payers during product development requires coordination with internal groups in both directions. Clinical groups need to share data with managed markets groups or HOLs, who then work directly with payers. But also, these payer groups should be allowed to provide input on trial design to make sure that the data outputs answer payer concerns. This government drug reimbursement study provides recommendations culled from interviews with leading life science leaders on meeting US government payers’ expectations and ensuring the desired reimbursement. Timeline data, including meeting duration metrics, will guide reimbursement teams in planning and making the most out of payer relationships.

Extend US Government Drug Reimbursement Team Capabilities through Structure and Resources: Differences in teams’ structure preferences are largely due to their company size and dependence on government drug reimbursement. All surveyed small companies have centralized government drug reimbursement teams, whereas some large companies choose to assign reimbursement responsibilities by brand, therapeutic area or development stage. And just as government reimbursement structures vary, so does annual spending for activities. This study includes diagrams illustrating real companies’ US government reimbursement team structures, as well as benchmarks showing budgets and outsourcing levels for these teams.

Anticipate Payer Expectations to Gain Superior Reimbursement: Attaining reimbursement does not have to be a complex process. State organizations often work with drug and device manufacturers to outline their needs and expectations for product dossiers. The best practices and strategies in this report present a roadmap for market access and US reimbursement teams to navigate state and federal payers’ processes and provide them with the necessary data to obtain a competitive formulary position and price.

You may also be interested in our market access library or individual market access research reports.

Key Questions This Study Answers About US Government Drug Reimbursement

  1. When should teams begin discussing their new products with payers?
  2. How often should these meetings occur throughout product development, and how long should individual meetings last?
  3. Which functions are involved in key pricing calculations, including average manufacturer price (AMP), best price (BP) and quarterly rebates?
  4. What documentation and standard operating procedures (SOPs) have forward-thinking companies implemented, and how have they facilitated government reimbursement processes?
  5. What are the advantages of a centralized team structure versus one that maintains specialized roles?

Price $1,995
Publication Date November 2014
Pages 55
Chapters 3
Metrics 200 +
Charts / Graphics 25 +