OBJECTIVES: To understand how therapeutic area (TA), treatment advances, and model quality influence payers’ interpretations of pharmacy budget impact (BI) model results, and to identify utilization management (UM) strategies that payers most frequently implement for drugs with low to high BI.

METHODS: An online survey was conducted with a panel of healthcare decision makers from Xcenda’s Managed Care Network. Participants were asked how their general perception of a low pharmacy BI may differ across 5 high-spend TAs. Similarly, the survey assessed how the threshold for a low BI may change based on disease rarity, model quality, and drug characteristics representing treatment advances. Finally, participants were asked to state their likelihood of implementing specific UM strategies based on their definition of low, moderate, and high BI. BI was described in per-member-per-month terms, and response options were in Likert scale. Descriptive statistics were used to summarize the data.

RESULTS: Out of 41 total participants, most were pharmacy and medical directors (63% and 27%, respectively). When considering TA, more than half stated that rheumatology, oncology, and neurology have higher thresholds for low BI than baseline. Drugs for a rare condition or that reduce mortality had at least slightly increased thresholds for low BI in 44% and 63% of participants, respectively. Considerations that had no impact on most participants’ BI thresholds were drug novelty (54%), model quality (54%), and drugs that improve quality of life (51%). On average, quantity limit was the most likely UM strategy for drugs with low BI, while prior authorization had the highest likelihood with high BI drugs.

CONCLUSIONS: Payers’ perceptions of low or high BI do not appear to be fixed thresholds but instead depend on several factors, including TA and a drug’s impact on mortality. Frequency and diversity of potential UM strategies increase as perceived BI increases.