BLOG: Generic Restasis upends dry eye marketplace
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Whoa! That sure happened fast. Did you see that coming? The whole dry eye marketplace turned upside down in — what? — 6 weeks?
That’s pretty much when “Fauxstasis” (cyclosporine A 0.05% in some kind of oily stuff, Mylan) was approved, and we almost immediately began to get pharmacy requests to switch patients. Sometimes before they even showed up to refill their Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan). After my recent update, I was expecting to give you my thoughts on what might happen now that Fauxstasis had been joined in the market by two real generic versions of Restasis manufactured by Allergan itself.
But before I could do that, it all actually went ahead and happened!
After returning from the American Society of Cataract and Refractive Surgery meeting, I was ready to tell you that upon reaching the magic number of three generics, the commercial market (younger than age 65 years) was going to become a full-on “step therapy” market. In order to have your patient on a branded medication — Restasis, Cequa (cyclosporine ophthalmic solution 0.09%, Sun Pharmaceutical) or Xiidra (lifitegrast ophthalmic solution 5%, Novartis) — they would first have to “fail” in some way on a generic; failure would be either a lack of clinical efficacy or intolerable side effects. This is well underway. Give up all hope of choosing which generic version your patient receives. This game is nothing but a race to the pricing bottom, and your patient will get whichever version is the cheapest one at the precise moment it is handed over by the pharmacist or mail carrier.
Medicare, on the other hand, would continue to be a branded universe. I felt that all three companies (Allergan, Sun and Novartis) would negotiate a “brand over generic” policy with the Part D insurers, with Allergan continuing to have a lock on the pole position on most formularies. So, classic generic disruption in the under-65 commercial space and status quo for seniors covered by Part D. There was no reason to expect any generic-driven change in how immunomodulators were covered by Part D.
Quarantined in my COVID bubble (literally; we have a plastic bubble on our porch), I was stunned to learn that Novartis was sending its sales force out with the news that Xiidra would be covered at par with Restasis, without prior authorization, for the overwhelming majority of Part D plans (Humana is the notable exception). Not only that, but word on the street is that Eysuvis (loteprednol etabonate ophthalmic suspension 0.25%, Kala Pharmaceuticals) will get similar treatment.* Just like that, the dry eye disease market has been upended.
What does it all mean at the slit lamp when you are getting ready to treat your patient with dry eye? More to come.
*No information was available regarding Part D and Cequa at the time this was written.
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