Narrow networks for specialty pharmaceuticals: good or bad for patient outcomes?

Narrow networks are an option for drug distribution that more specialty pharmaceutical companies are choosing: By providing drug to a limited list of specialty pharmacies, manufacturers can monitor follow-on care more closely; limit drug diversion to other distribution channels; and, in some instances, ensure that more revenue flows back to the manufacturer after all the discounting, rebates and coupons are adjudicated (by providing valuable patient-support services, though, the manufacturer might also be incurring additional costs). The downside is that patients may have a harder time obtaining drug (especially if it is not available via mail delivery) and health systems with their own specialty pharmacies may incur higher costs to obtain drug for their patients.

CVS straddles this issue by both having a pharmacy benefit management arm (CVS/caremark), a specialty pharmacy network and the option for many patients to obtain a limited-distribution drug at a local CVS pharmacy (it has 7,800 locations). A just-published study in JAMA Internal Medicine finds justification for limited distribution in better medication adherence. According to the research letter published there, de-identified pharmacy claims data for more than 200,000 patients on chronic therapies to treat high cholesterol, high blood pressure, diabetes and depression over a 12-month period showed improved adherence to therapy. The effect was quite small: 1.00-1.65% improvement in medication possession ration (MPR—one way to measure adherence) between in-plan and out-of-plan CVS/caremark patients. Still, better adherence almost axiomatically results in better outcomes.

Given that the data covers a range of specialty, non-specialty, branded and generic drugs, and given that any intervention (whether via a limited-distribution network or not) will probably show some benefit, the study isn’t the last word on the topic. Now, however, what looks like a real head-to-head comparison is setting up between Amgen and Sanofi, both of whom have just received approval to market their PCSK9 anti-cholesterol drugs. Sanofi is going the route of a limited-distribution network for Praluent; Amgen is going with a more open distribution. Both drugs are priced in the specialty range (at around $14,000 for a year’s worth), and while there could be medical or physiological differences in the drugs in terms of patient acceptance, they are relatively similar treatments with the same mode of action. Sanofi tells prescribers, in its online product-support page, how to obtain the drug from its network; Amgen, on its “RepathaReady” page, tells “patients & providers” what documentation to take to “the pharmacy of their choice.”

Both Amgen and Sanofi appear to be deploying the full range of resources for specialty pharmaceutical distribution: copay cards, initial fills before prior authorizations are worked out; telephone support for physicians’ offices and for patients; and patient assistance programs. If nothing else, the programs show that for today’s specialty pharmaceutical companies, getting a drug through FDA approval is just the beginning of the race to commercial success. How well the two approaches test the impact of limited distribution will depend on what actions both companies take after product launch.