Neil Minkoff, MD: In the world we live in, is there a pathway where we start with generic because it’s the least expensive? Ten years ago, we thought it was the bee’s knees. We use that to try to do some level of incremental therapy. Dr Lopes, is that something that you think is happening or will happen? Dr Ross, is that something you’re seeing? Is it affecting your patients? Dr [Thomas] Leist, I want to bring you back after I hear where we are, boots on the ground, with that.

Maria Lopes, MD, MS: Yes, it is. And as classes get more crowded with alternatives where there are generics, payers are looking at this, but it also may reflect on the patient cost share. If a patient is paying a coinsurance and it’s a $1200-per-month drug vs maybe $3000 per year, that may have very different implications for patient affordability. Albeit on the commercial side, there are usually co-pay assistance programs. We try to move more in the direction of co-pay maximizers so that if patients have the assistance, it’s amortized. The savings is amortized over the full year as opposed to just up front, which often leads to patients then discontinuing when they’re running out of patient assistance.

It’s really hard. As we think about pipelines and new products that are coming to market as well as those that are losing exclusivity, it’s hard not to factor in the opportunity of potentially more management within a class and the opportunity to prefer, or maybe even step through, a generic alternative before you go to something that has significantly higher cost.

Neil Minkoff, MD: Dr Ross, you’re the 1 dealing with this from the other point of view, which is trying to navigate the patient, work them through the system, try to determine if it’s appropriate for them to step through generic or whatever they’ve already tried in the past, and so on. How is this impacting your patients? I hate to be dramatic, but can you put more of a human face on it? Because we’re having this academic discussion about MOAs [mechanisms of action] and so on.

Nancy Ross, PharmD, BCACP, MSCS, CSP: This has pretty much been my entire life since January. On January 1, 2021, every payer flipped over from branded Tecfidera to generic dimethyl fumarate. For all these years, Tecfidera’s big thing has been, “We don’t want cost to be a barrier to your treatment, so we’re going to give you all the co-pay assistance you can stand. No co-pays anywhere you go.” On January 1, Tecfidera was suddenly the enemy, and all the patients had to flip over. Unfortunately, we have 500 Tecfidera patients. it’s not like we could really notify them ahead of time that this was coming, so they hit all this. Half of them have argued for the brand. Some of them are going to Vumerity. Some of them are going to generic.

The generic is fine. It’s an A-rated generic. I don’t have any problems with the generic. It’s great that payers want to put that on their formulary first and save money. But the problem comes down to co-pay. Patients have gotten very used to not paying anything for their MS [multiple sclerosis] treatment. We preach to them, “You should not have to pay for your MS treatment. There are tons of resources out there for you. There are all kinds of co-pay systems. Please don’t let money be the reason you can’t take this medication.” Now they have a $1200 co-pay, a $1500 co-pay, a $650 deductible, and then $125 per month. This is suddenly a really big issue, and payers are going to run into a real issue because patients are going to push against using the generic simply because they can’t afford it. If payers want patients to continue to use generic products, they’re going to have to reduce the cost of these generic specialty medications. This is going to be more of a problem when we hit generic Aubagio and generic Gilenya. If payers don’t reduce the cost, all these patients are going to flip to the manufacturer’s newest, coolest thing, such as Vumerity, and then we’re all going to be in the same problem again.

Transcript edited for clarity.