Advancing adult immunization: Exploring the pricing and access landscape for combination vaccines

Jennifer Wong

Published in

ZS Associates

9 min readAug 20, 2024

By: Jennifer Wong and Elvan Sen

1. Introduction

Combination vaccines have long been recognized for their benefits in pediatric immunization programs: they successfully improve vaccination rates, reduce healthcare resource utilization (HCRU), and promote public health equity.

There remains a significant opportunity to meaningfully leverage this innovation in the adult population. While the routine vaccination rate among school-aged children in the US is greater than 90%, the coverage for routine adult vaccinations, such as Pneumococcal and Herpes Zoster, is reported to range from only 20 to 62%. Similar disparities exist across Europe. The older adult coverage for pneumococcal vaccination, for example, is ~24% compared to ~88% for children¹²³.

In our previous blog, we laid out key hurdles and catalysts driving the development of combination vaccines indicated for adults, and in our webinar, focused on the short and long-term adult vaccination landscape.

Given existing coverage challenges, understanding the pricing and access nuances and implications for adult combination vaccines is crucial to a successful launch and future uptake.

In this article, we explore pricing and access considerations in this evolving space and deep dive on what may be required to unlock the full potential of adult combination vaccines.

2. Payer value drivers and barriers summary

Combination vaccine benefits and drawbacks warrant holistic consideration to develop a clear value proposition and pricing strategy

Let’s first examine the key value drivers and potential barriers for adult combination vaccines, specifically from the perspective of payers and other access decision-makers. Effectively articulating the nuances of how combination vaccines can benefit the healthcare system and their value proposition distinct from single-indication vaccines, as well as the inherent challenges that adult combination vaccines may pose, will provide crucial context for the subsequent discussion on pricing strategies and access considerations.

Key benefits or advantages from a payer point of view:

Fewer overall HCP visits for vaccine administration: There will likely be immediate, short-term cost-savings as patients can consolidate multiple visits for different vaccines into a single visit
Improving public health outcomes and overall disease coverage: Assuming no meaningful increase in patient out-of-pocket costs, the convenience of combination vaccines may lead to patients being vaccinated for more diseases. In addition to advancing health equity long-term, this can improve public health and relieve HCRU required for interventions of the individual diseases covered by vaccines
Increased supply chain efficiency: Distribution, storage, and disposal will be streamlined at the site of care (e.g., provider offices, pharmacies, etc.), increasing efficiencies and freeing up time spent on logistics
Fewer overall adverse events: Fewer injections would hypothetically lead to fewer instances for patients to have adverse events such as reactions at the injection site, which would also decrease any required intervention and associated costs

On the other hand, there are several challenges and concerns that payers will likely want addressed or mitigated:

Uncertainty on durability: Given the newness of combination vaccines for adults, payers may be concerned by the lack of long-term durability data and the budget impact of unanticipated boosters in the future
Uncertainty on efficacy and safety of individual components: It will be more challenging for payers to be convinced of the additional value offered through combination vaccines, especially if priced at a premium if the clinical benefits and safety outcomes cannot be attributed to each single indication component. From a safety perspective, payers will also want to ensure there is no suppression or impact on the efficacy of one component on another component due to the combination
Need for new logistical investment: Providers of adult combination vaccines will need to prevent misaligned vaccination schedules, and establish new protocols and pathways for tracking, monitoring, and compliance while ensuring that patients are not getting single indication vaccines that duplicate coverage already obtained through a combination vaccine
Potential higher price vs. single-indication vaccines: It is important to communicate the value associated with the long-term benefits given that the short-term budget impact may seem to be higher compared to single-indication vaccines

Navigating pricing methodologies for combination vaccines is not straightforward. Factors such as the cost savings from reduced injections, lower administration burden, and potentially decreased storage requirements should be considered in the overall price discussion. For vaccines that can be administered within the pharmacy setting, pharmacies will also be looking to maintain favorable revenue margins, with due consideration given to operational factors of inventory stocking and administration.

3. Current combination vaccine pricing

What precedent is there to draw from for adult combination vaccine pricing in the market?

A small pool of pediatric combination vaccines globally to date leads to a less clear picture of past pricing and coverage trends. However, this challenge highlights a unique opportunity to shape the evolving landscape of adult combination vaccines from a price and access perspective.

In the US, combination vaccines for pediatrics have varying pricing levels compared to their single-indication vaccine counterparts. The list price or overall cost of vaccination per patient may be higher, on par, or lower for a combination vaccine. This makes it challenging to draw meaningful predictions from the current pricing of combination pediatric vaccines for future combination adult vaccines.

For example, ProQuad®(MMR/Varicella), priced at $178 per dose under CDC is slightly more (5%) than the sum of its single indication components per dose⁴

On the other hand, Penbraya™ (for MenABCWY) list price at $189, compared to MenB vaccines at $136-$150 and MenACWY vaccines ($111-$150) under CDC remains lower (~25%) with overall fewer of doses needed.⁴ Factors which may have influenced this lower pricing of Penbraya may include the disruption of the existing vaccine scheduling, and tat the MenB vaccination was recommended through shared clinical decision-making (SCDM).

4. Adult combo Vx pricing opportunities

Considering the limited examples in the pediatric landscape, what are the adult combination vaccine pricing opportunities?

To assess the potential revenue and commercial opportunity, key factors include but are not limited to:

Availability of single indication or combination vaccines for the components
Unmet need and disease burden for the single indication vaccine components
Target population size and demographics
Priority of the disease from a public health standpoint within a specific geography (e.g., where factors such as climate or seasonality may impact how much the disease affects the population)
Perceived incremental value of the combination vaccine for the healthcare system (incl. reduced HCRU, burden, and potential risk of infection for the immunocompromised/frail patients through repeated visits of single injections, faster to inoculate in long-term facilities, and stimulate vaccine rates for certain diseases)

These elements can impact the willingness to pay or uptake from stakeholders beyond payers, such as physicians, providers, pharmacies, and patients, and therefore must be incorporated into the strategic planning process.

On the pricing front, there are 3 main frames of reference being used as a starting point that we may consider, through examples of vaccines for Disease X and Disease Y:

1. Linear pricing, the 1 + 1 = 2 method: The seemingly most straightforward calculation, where the combination vaccine is priced at the total price of the single indication components considered in isolation. While simple, this methodology is less likely to reflect the reality and complexity of how payers will value the potential benefits of a combination vaccine for adults.

2. Weighted pricing: A more nuanced version of linear pricing may take into account the perceived value of each of the single indication components and assign weights for an ultimate weighted average. This could help account for the price favoring the vaccine for a disease that has a higher burden or unmet need than the other in the combination or any nuances in the target patient population of single indication components. For example, a well-established antigen/vaccine component may be assigned a lower weight, being perceived as relatively less valuable compared to a more uncommon antigen.

3. Premium pricing: Payers may also be open to a premium pricing for assets with strong value propositions with competitive advantage, including those that enhance the vaccination rates of the individual components (especially if they were low), and demonstrated long-term cost-savings, either using a linear or weighted pricing methodology can be used which will impact the price potential.

While these methodologies might start to inform potential pricing narratives and negotiations, several remaining unknowns, including purchasing agreements, potential portfolio contracts, and supply initiatives, will likely impact overall payer or purchaser decision-making and are worth further exploring. Also, over time, as more combination vaccines are priced, they will set their own benchmarks for future vaccine combos.

Beyond the potential cost-savings and the broader advantages and disadvantages of combination vaccines that may impact willingness-to-pay, the reviews and recommendations from health technology assessment (HTA) bodies and vaccine authorities will also significantly influence the positioning, adoption, and pricing of adult combination vaccines, especially in markets with universal healthcare systems.

5. Geographic and regional nuances

What are some of the key market-related dynamics to take into account?

From a regional perspective, manufacturers must assess the local needs for vaccine evaluation and coverage to ensure optimal value and evidence communication. In the US, nuances of Medicare Part D and Part B coverage are crucial to understand as their dynamics may influence pricing. As an example, while Part D covers most vaccinations, including for RSV, COVID-19, and influenza, vaccines are covered under Part B⁵ ⁶, and this evolving landscape, with the upcoming introduction of combination vaccines targeting a variety of such infectious diseases, will be interesting to observe closely from a market access perspective. Another factor to consider is portfolio contracting, which can enable higher premiums for a new high-value combination vaccine based on the overall portfolio strength, and how much of its other elements are leveraged to achieve this goal. Vaccine purchasers can prefer incentives such as discounts and rebates decided at a portfolio level, given the lower impact of vaccine clinical profile differences. Convenience can also play an important role. Therefore, combination vaccines can become attractive options if blended with contracting terms, including manufacturers’ broader vaccine portfolios.

For countries like Germany, the UK, Italy, Japan, and Canada, cost-effectiveness analyses and value-based pricing models that account for the benefits of reduced injections and improved compliance can be crucial in securing favorable reimbursement from payers. Procurement channels and negotiation methods (e.g., via national or regional tenders) will also play a pivotal role in determining the commercial success of adult combination vaccines.

6. Conclusion — Future of combo Vx pricing

How can we further position adult combination vaccines for success from an access and pricing perspective?

The development and strategic pricing of adult combination vaccines present a promising opportunity to drive meaningful improvements in immunization coverage and public health outcomes. However, a paradigm shift in regulatory, policy, and financing perspectives is needed to fully recognize their intrinsic value. By moving away from the traditional view and pricing these products to reflect their added convenience, compliance benefits, and broader economic value, adult combination vaccines can become game-changers in solving the challenges of adult immunization. Ultimately, the future success of these vaccines hinges on balancing commercial viability with widespread accessibility and adoption through a strategic approach.