Inside the Decision Room: What Really Drives Formulary Placement
Last week, we explored how payers are scrutinizing endpoints and comparators more closely than ever, and why validating your value story against payer expectations has become essential. But validation is only half the battle.
Once your evidence is ready, it still needs to withstand the toughest test: the P&T (Pharmacy & Therapeutics) committee.
That’s where tools like MAVA™ come in. Think of it as a way to pressure-test your strategy before the real performance. By engaging real payer and provider decision-makers in a blinded environment, manufacturers can see how their value story holds up — and refine it before stepping into the formulary conversation.
What Happens Inside the Room
The P&T committee isn’t a single voice. It’s a mix of pharmacy directors, medical directors, clinicians, and financial decision-makers. Each brings a different perspective:
- Pharmacy directors weigh the impact on budgets, utilization management, and operational feasibility.
- Medical directors and clinicians focus on endpoints, comparators, and evidence relevance.
- Finance stakeholders consider rebate thresholds, contracting tradeoffs, and long-term risk exposure.
When they deliberate, your brand is competing against other therapies — not only on net cost, but on clarity, credibility, and confidence in its value proposition.
Beyond Rebates: What Payers Look For
From recent payer panels and advisory sessions, several consistent themes have emerged:
- Evidence relevance matters: Endpoints must connect to real-world outcomes. If trial results don’t translate into patient or system value, skepticism grows.
- Comparator choice is critical: Committees quickly flag if a trial stacks the deck against a weak comparator. They want to see how your therapy performs against real market alternatives.
- Budget impact clarity: Rebates help, but decision-makers want models that show how cost offsets play out over time — from reduced hospitalizations to avoided complications.
- Contracting creativity: Standard rebates aren’t always enough. Outcomes-based contracts, step-edit removal agreements, and innovative risk-sharing approaches often carry more weight than flat discounts.
- Consistency of story: Misalignment between Commercial, Medical, and HEOR messages raises red flags. A cohesive, validated value narrative is essential.
How Manufacturers Can Prepare
High-performing teams don’t walk into the access conversation with only price in hand. They:
- Test value stories early with payer panels to understand where skepticism lies.
- Validate evidence assumptions before finalizing dossiers and contracting strategies.
- Scenario-plan rebate thresholds to understand where flexibility exists — and where pushback is inevitable.
- Equip field teams with clear narratives that can withstand cross-functional questioning.
By entering the room with a validated, payer-tested value story, manufacturers increase the likelihood of securing favorable placement — without overreliance on unsustainable rebate levels.
The Bottom Line
Validating your endpoints and comparators is step one. But inside the P&T committee, payers push beyond validation. They test whether your evidence aligns with market realities, budget impact, and contracting creativity.
Rebates may open the door, but only a cohesive, payer-tested value story will carry you across the threshold.
That’s why leading teams use MAVA® to pressure-test their strategy so there are no surprises when the formulary decision is on the line.
Want to learn more? Let’s talk: info@emaxhealth.net