Brilinta could finally get a chance to shine

A value-based deal would boost prices should Astrazeneca's struggling heart-disease pill Brilinta outperform outcomes benchmarks.

Value-based pharma contracting is evolving. This could be one conclusion to take away from today's announcement from UPMC Health Plan, an insurer, which promised to boost its reimbursement to Astrazeneca for Brilinta should the heart-disease pill exceed prevention expectations.

In clinical trials Brilinta has shown that it can reduce the risk of cardiovascular death or heart attack compared with Plavix, but its cost – 23 times that of Plavix – has made it difficult for physicians to justify prescribing it to patients, especially those with significant cost-sharing obligations. “Some plans would say, ‘We don’t need that drug. We’ve got Plavix’. I think it’s the perfect agent to put a value-based contract around,” Chronis Manolis, the health plan’s chief pharmacy officer, tells Vantage.

Slow uptake

Brilinta, at one time thought to be capable of generating multi-blockbuster sales, has failed to live up to pre-launch expectations, something that is partly related to its cost; its revenues finally tipped over the $1bn mark in 2017, six years after launch. On average Medicare spent $1,734 per patient prescribed Brilinta in 2016, compared with $73 for generic clopidogrel, Plavix's active ingredient.

Repeated clinical failure as Astra has attempted to expand indications is another explanation for its commercial underperformance; the $3.5bn sales figure cited as it tried to fend off a takeover from Pfizer five years ago will almost certainly never materialise.

Sellside sours on Brilinta - forecasts over time
    Forecast WW sales ($m)
Forecast date Phase 2016e* 2018e 2020e 2022e 2024e
Jan 2019 Marketed 839 1,297 1,637 1,641 1,371
Dec 2017 Marketed 839 1,345 1,694 1,731 -
Dec 2016 Marketed 841 1,312 1,667 1,687 -
Dec 2015 Marketed 861 1,445 1,982 - -
Dec 2014 Marketed 929 1,345 1,613 - -
Dec 2013 Marketed 779 1,077 - - -
Dec 2012 Marketed 1,194 1,617 - - -
Dec 2011 Marketed 2,183 - - - -
Dec 2010 Filed 2,222 - - - -
*Dec 2017 and Jan 2019 are actual reported sales figures. Source: Evaluate Pharma

The price difference probably helps explain why Medicare spent $229m on branded and generic versions of Plavix, and just $209m on Brilinta in 2016, with 119,000 patients taking the Astra pill to nearly three million for clopidogrel. This is in spite of Brilinta's ability to reduce the risk of cardiovascular death, myocardial infarction or stroke by 16% in the 12 months after a cardiovascular episode, not to mention a 33% reduction in the risk of stent thrombosis for those undergoing a percutaneous coronary intervention.

“This is an important drug if you’ve had a myocardial infarction,” Mr Manolis says. “But it’s a branded drug in a theoretically generic class.”

The contract applies to patients in Medicare plans at the University of Pittsburgh Medical Center (UPMC). As with value-based contracts that have preceded this, Astra will deepen its discount if Brilinta does not meet an undisclosed outcomes benchmark. In a new twist, however, if it outperforms UPMC will increase reimbursement.

Mr Manolis says UPMC does not mind paying more in that scenario, because the overall health system savings would “dwarf” the additional payments to Astra.

Better access

Significantly, the contract puts Brilinta in the same tier as generic drugs rather than as a preferred or non-preferred branded drug, and this will reduce cost-sharing to the lowest levels. Thus, the difference in cost-sharing should be massive for patients in UPMC plans.

An Astra spokesperson says this is the first value-based contract on Brilinta that has resulted in the lowering of patient cost-sharing to generic levels. The pill is covered by nearly all Medicare and commercial health plans.

UPMC claims 200,000 members in its Medicare plans, largely in western Pennsylvania. While value-based contracting has been a means to cut prices, biopharma companies should welcome the opportunity to see a reimbursement boost based on improved outcomes. Whether they are able to take advantage of this chance will depend, of course, on the benchmarks. 

Clinical trial outcomes are hard to duplicate in the real world, and it will take a sustained effort to make sure that the most appropriate patients receive the drugs and adhere to their prescriptions.

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