Pharmaceutical Pricing and Reimbursement in the United States, 2008

Table of Contents

• Executive Summary
  • Strategic Considerations
  • Stakeholder Implications
• Overview
• Organization and Funding of the U.S. Health Care System
  • Private Insurance
  • Medicare
  • Medicaid
  • Military and Other Federal Health Care Programs
• Pharmaceutical Prices in the United States
  • Prices Relative to Other Major Markets
  • Pricing in the Public Sector
  • Pricing in the Private Sector
  • Generics Pricing
• Provider Reimbursement
  • Medicare
    • Hospital Inpatient Treatment
    • Hospital Outpatient Treatment
    • Offi ce-Based Physicians
  • Commercial Insurers
• Coverage Decision Making
  • Public Sector
  • Private Sector
• Cost-Containment Measures
  • Multitier Formularies
  • Patient Copayments and Coinsurance
  • Use of Generics
  • Therapeutic Substitution
  • Prior Authorization and Step Therapy
  • Specialty Pharmacy
• Health Technology Assessment in the United States
  • Academy of Managed Care Pharmacy
  • Agency for Healthcare Research and Quality
  • Drug Effectiveness Review Project
  • Medicare
  • HTA Outlook
• Outlook for the U.S. Pharmaceutical Market

Tables

• 1. Health Insurance Coverage of the U.S. Population, 1999-2006
• 2. Medicare Part D: Key Parameters of the Standard Drug Benefi t Design, 2006-2008
• 3. Multilateral Comparison of Average Ex-Manufacturer Prices of Branded Medicines in Select Markets as a Percentage of U.K. Average Ex-Manufacturer Prices, 1992-2004
• 4. U.S. Prices of Select Drugs as a Percentage of Average Prices in Six Other Major Pharmaceutical Markets, 2006
• 5. Prices of Leading Biologics in the Major Markets as a Percentage of U.S. Prices, 2006
• 6. Pricing Benchmarks in the United States
• 7. Technologies That Have Pass-Through Status in the Medicare Outpatient Prospective Payment System, 2008
• 8. Key Features of Medicare Inpatient and Outpatient New Technology Payment Mechanisms
• 9. Frequency with Which Pharmacy and Therapeutics Committees Consider Select Drug Attributes in Formulary Decision Making (%)
• 10. Frequency with Which Pharmacy and Therapeutics Committees Consider Select Drug Attributes in Formulary Decision Making (mean scores)
• 11. U.S. Employers' Views on Strategies to Increase Prescription Drug Benefi t Value, 2005
• 12. Bills Introduced in the 110th Congress to Promote Comparative Effectiveness Research
• 13. Key Trends of Change in the U.S. Prescription Drug Market: Implications for the Pharmaceutical Industry

Figures

• 1. Percentage of the U.S. Population Covered by Various Forms of Health Insurance
• 2. Percentage of Covered Workers Enrolled in Various Types of Health Plan, 1998-2007
• 3. Medicare Benefi ciaries' Sources of Health Care Coverage, January 2007
• 4. Standard Medicare Part D Drug Benefi t Design, 2008
• 5. Annual Deductible Policies of Standalone Medicare Prescription Drug Plans and Medicare Advantage Plans, 2008
• 6. Detailed Coverage Gap Policies of Standalone Medicare Prescription Drug Plans, 2008
• 7. Detailed Coverage Gap Policies of Medicare Advantage Plans, 2008
• 8. Medicaid Pharmaceutical Expenditures, 1996-2006 (estimated)
• 9. Average Prices of Leading Biologics, Small-Molecule Drugs, and Pharmaceuticals Overall in the Major Markets as a Percentage of U.S. Prices, 2006
• 10. Comparison of Prices of Select Branded Medicines and Generics for Customers With and Without PBM Membership, 2002
• 11. Average Rebates Per Prescription Received by U.S. Employers, 2007
• 12. Employers' Perceptions of Pharmacy Benefi t Management Companies' Impact on Their Overall Drug Costs, 2002 and 2005
• 13. Average Price of Brands and Generics As a Percentage of Respective Brands' Price Prior to Generic Entry
• 14. National Coverage Determination Process of the Centers for Medicare and Medicaid Services
• 15. Important Factors for Making Reimbursement Decisions
• 16. Percentage of Covered Workers in Formularies of Various Structures, 2000-2007
• 17. Percentage of Employers Using Formularies of Various Structures, 2007
• 18. Percentage of Medicare Standalone Prescription Drug Plans Offering Formularies of Various Designs, 2006-2007
• 19. Percentage of Medicare Advantage Plans Offering Formularies of Various Designs, 2006-2007
• 20. Importance of Clinical and Nonclinical Factors to Tier Placement