Kelly Price: There Is Pressure for Payers to Cover PDTs

At the Academy of Managed Care Pharmacy Nexus 2022 fall meeting, Kelly Price, US Head of Rare Disease at HRA Pharma, expands on trends in the prescription digital therapeutic (PDT) market and pressure on a decision whether they will be covered by insurance.

Transcript

What are some key trends impacting the PDT market?

I think right now what we're seeing is, [for] payers, there's pressure for a decision—are these going to be covered or not? And I think patients and providers are both looking specifically to the big 3 payers—[Evernorth, Caremark, Optum]—and asking for them [to cover PDTs], because none of them have any coverage of PDTs.

But now there's 9 [PDTs] on the market, and what are we going to do? Are we going to cover or not? Are patients going to be asked to self pay or not? So, I think that's the biggest trend recently, where there is now a situation where we're like, "Okay, we understand, we want to write [a prescription], but are they covered?"

How are payers and providers ensuring patients have access to PDTs?

I don't think we're there yet. I think the answer is we're not, we're not ensuring [access]. What we're seeing is the option for patients to self pay, but that's concerning. We see over 50% of the population now is in a high-deductible plan. We know that [in] the high-deductible plans, the Kaiser [Family] Foundation tells us that deductibles aren't being met until about the end of May is when we see most deductibles being met.

So, a lot of people are operating—a lot of patients, a lot of families are operating—in a cash pay health care setting up through May if you're in a high deductible. So, those patients may be used to paying cash out of pocket, but then there's the rest of the population that isn't, and they're not going to use something unless it's covered by the insurance they pay a lot of money for.

I don't think there's any ensuring of coverage, I think that's why we're still in the midst of a pretty strong fight, but I think that if we continue to prove value in the market then coverage will follow, is my belief.