RARE DISEASES AND ORPHAN PRODUCTS

Accelerating Research and Development

Committee on Accelerating Rare Diseases Research and Orphan Product Development

Board on Health Sciences Policy

Marilyn J. Field and Thomas F. Boat, Editors

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

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Committee on Accelerating Rare Diseases Research and Orphan Product Development Board on Health Sciences Policy Marilyn J. Field and Thomas F. Boat, Editors

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THE NATIONAL ACADEMIES PRESS • 500 Fifth Street, N.W. • Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. N01-OD-4-2139, TO # 215 between the National Academy of Sciences and the National Institutes of Health. Additional support was provided by the Food and Drug Administration. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the view of the organizations or agencies that provided support for the project. International Standard Book Number-13: 978-0-309-15806-0 International Standard Book Number-10: 0-309-15806-0 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www. iom.edu. Copyright 2010 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Front cover photographs (top to bottom): Using electropheresis apparatus to separate proteins by molecular weight. Photo courtesy of National Institute of Arthritis and Musculoskeletal and Skin Diseases. 96-well, 384-well, and 1,536-well plates used in pharmaceutical and life science research. Photo courtesy of National Human Genome Research Institute. Children with ectodermal dysplasia. Used with permission. Photo courtesy of the National Foundation for Ectodermal Dysplasias. Image of chromosomal abnormalities in mouse cells from a study of leukemia-promoting effects of tumor necrosis factor-alpha in Fanconi anemia group C stem cells. Photo courtesy of the laboratory of Dr. Qishen Pang at Cincinnati Children’s Hospital Medical Center. U.S.A. Copyright 2007, American Society for Clinical Investigation. Used with permission. Friedreich’s ataxia patient and Friedreich’s Ataxia Research Alliance (FARA) spokeperson, Kyle Bryant, on his recumbent trike during the cycling competition Race Across America. Copyright 2010, www.SLOtography.com. Used with permission. Children with sickle cell disease. Used with permission. Photo courtesy of Cincinnati Children’s Hospital Medical Center. Suggested citation: IOM (Institute of Medicine). 2010. Rare Diseases and Orphan Products: Accelerating Research and Development. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding en- gineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON ACCELERATING RARE DISEASES RESEARCH AND ORPHAN PRODUCT DEVELOPMENT THOMAS F. BOAT (Chair), Executive Associate Dean, University of Cincinnati College of Medicine PETER C. ADAMSON, Chief, Clinical Pharmacology and Therapeutics, Director, Office of Clinical and Translational Research, Children’s Hospital of Philadelphia CAROLYN ASBURY, Chair of the Board, National Organization for Rare Diseases, Senior Consultant, Dana Foundation, Senior Fellow, Leonard David Institute PAUL CITRON, Vice President of Technology Policy and Academic Relations, Medtronic Inc. (retired), Senior Fellow, School of Engineering, University of California, San Diego PETER B. CORR, Founder and General Partner, Celtic Therapeutics LLP MICHAEL DEBAUN, Ferring Family Chair in Pediatrics and Professor of Biostatistics and Neurology, Washington University in St. Louis, Director, Sickle Cell Medical Treatment and Education Center, St. Louis Children’s Hospital HARRY C. DIETZ, Victor A. McKusick Professor of Medicine and Genetics and Professor of Pediatrics, Institute of Genetic Medicine, Johns Hopkins University School of Medicine ELLEN J. FLANNERY, Partner, Covington & Burling LLP PAT FURLONG, President and Chief Executive Officer, Parent Project Muscular Dystrophy MARLENE HAFFNER, President, Haffner Associates LLC HAIDEN HUSKAMP, Professor of Health Care Policy, Harvard Medical School ANTHONY SO, Professor of the Practice of Public Policy Studies, Director, Program on Global Health and Technology Access, Duke University ROBERT D. STEINER, Credit Unions for Kids Professor of Pediatric Research, Vice Chair for Research, Faculty: Program in Molecular and Cellular Biosciences, Pediatrics, and Molecular and Medical Genetics, Child Development and Rehabilitation Center, Doernbecher Children’s Hospital, Oregon Health & Science University NANCY S. SUNG, Senior Program Officer, Burroughs Wellcome Fund Consultants LAURA BROOKS FADEN, Doctoral Student, Harvard University Program in Health Policy v

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AARON SETH KESSELHEIM, Instructor in Medicine, Harvard Medical School; Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital ALISON MACK, Independent Consultant IOM Staff MARILYN J. FIELD, Senior Program Officer CLAIRE GIAMMARIA, Research Associate (from August 2010) ERIN S. HAMMERS, Research Associate (until May 2010) ROBIN E. PARSELL, Senior Program Assistant ANDREW M. POPE, Director, Board on Health Sciences Policy vi

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Acknowledgments In preparing this report, the committee and project staff benefited greatly from the assistance and expertise of many individuals and groups. Important information and insights came from three public meetings that the committee organized to collect information and perspectives from a range of academic, professional, consumer, patient, and other organiza- tions and individuals. A number of speakers at these meetings also shared their knowledge at other times during the course of the study. Appendix A includes the agendas of the public meetings and a list of organizations that submitted written statements of views. The committee appreciates the con- tributions of Aaron Kesselheim, author of Appendix B, and Laura Brooks Faden, coauthor of Appendix C. Our project officer at the National Institutes of Health (NIH), Stephen Groft, was an invaluable resource and unfailingly helpful. We also were advised by others at NIH including Stephen Hirschfield (National Institute for Child Health and Human Development) and Jeffrey Abrams and Isis Mikhail (National Cancer Institute). Our project officer at the Food and Drug Administration (FDA), Timothy Coté, likewise was a great help, pa- tiently answering questions about the workings of the Orphan Drug Act and its results. We also were assisted by other FDA staff, particularly Debra Lewis and Anne Pariser as well as Kui Xu, Menfo Imoisili, and Katherine Needleman. Joan Sokolovsky at the Medicare Payment Advisory Com- mission helped with questions about drug coverage under Medicare Parts B and D. Scott Grosse at the Centers for Disease Control and Prevention offered useful insights into the complexities of epidemiologic research on rare conditions. vii

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viii ACKNOWLEDGMENTS Sharon Terry and colleagues at the Genetic Alliance and Peter Saltonstall, Mary Dunkle, and colleagues at the National Organization for Rare Dis- eases worked with the committee on an invitation for their members to submit statements of views on issues before the committee. At Orphanet, Seygolene Ayme provided important information and guidance about their information resources. A number of individuals in other organizations were also helpful in a variety of ways. In addition to those who made presenta- tions during committee meetings and with whom we talked at other meet- ings, among those we consulted were Stephen Bajardi and Anthony Horton (International Rett Syndrome Foundation), Ron Bartek (Freidriech’s Ataxia Research Alliance), Robert Beall (Cystic Fibrosis Foundation), Wendy Book (American Partnership for Eosinophilic Disorders), Amy Hewitt (Sclero- derma Research Foundation), Cynthia Joyce (Spinal Muscular Atrophy Association), Jill Raleigh (LAM [Lymphangioleiomyomatosis] Foundation), Jodi Edgar Reinhardt (National Foundation for Ectodermal Dysplasias), and John Walsh (Alpha-1 Foundation). We also called on Carl Whalen at the National Disease Research Interchange; Yann Le Cam (Eurodis); Marty Liggett, Ulvana Desiderio, and Stephanie Kart (American Society of Hematology); Qishen Pang, Vicky Klensch, and Kori Siroky (Cincinnati Children’s Hospital Medical Center); and Enrique Seoane-Vazquez (Ohio State University). In addition, the committee and project staff appreciate the work of copy editor Florence Poillon; Debra Gilliam, Chanda Chay, and John Bowers of Caset Associates; and temporary research assistant Cassandra Fletcher. Within the National Academies, we particularly acknowledge the assistance of Clyde Behney, Adam Berger, Robert Giffin (now at the Center for Medi- cal Technology Policy), Greta Gorman, Christine Micheel, Amy Packman, Donna Randall, and Vilija Teel.

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published reports as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Ronald J. Bartek, Friedreich’s Ataxia Research Alliance Edward M. Basile, King & Spalding Jim Burns, Genzyme Corporation David Frohnmayer, Fanconi Anemia Research Fund Elaine Gallin, Doris Duke Charitable Foundation Robert C. Griggs, University of Rochester School of Medicine Susan Kelley, Multiple Myeloma Research Consortium Chaitan Khosla, Stanford University Michael Knowles, University of North Carolina at Chapel Hill Roger J. Lewis, University of California, Los Angeles John Linehan, Stanford University Dawn S. Milliner, Mayo Clinic Carol Mimura, University of California, Berkeley John A. Parrish, Massachusetts General Hospital ix

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x REVIEWERS Reed E. Pyeritz, University of Pennsylvania Joan Sokolovsky, Medicare Payment Advisory Committee Jess G. Thoene, University of Michigan Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Neal A. Vanselow and Floyd E. Bloom, Scripps Research Institute. Appointed by the National Research Council and the Institute of Medicine, these individuals were responsible for making certain that an independent examination of this report was carried out in accordance with the institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Preface Rare diseases are not rare, at least in aggregate. Approximately 7,000 rare diseases afflict millions of individuals in the United States and are re- sponsible for untold losses in terms of physical health, behavioral health, and socioeconomic condition. Physicians, nurses, and others who care for this group of patients recognize the huge burden on patients, families, com- munities, the health care system, and the health care financing system. All too frequently, providers are reminded of the gap between patient needs and our inability individually and collectively to meet those needs. Although rare diseases taken together have an enormous impact, there has been no “war on rare diseases” and no designation of a National Institutes of Health (NIH) institute (as for cancer) to address research on rare diseases, even though some U.S. prevalence figures for all rare diseases fall in the range of estimates of those with a history of a cancer diagnosis. Although neither of these cancer-specific responses to need may be suited to rare diseases, many patients with rare diseases today have difficulty in find- ing providers with the expertise and resources to diagnose and treat their conditions. In addition, research progress has suffered from segmented, disorder-specific approaches to projects and their funding. The Institute of Medicine committee was asked to examine the cur- rent state of research on health care for rare diseases and products to better prevent, diagnose, and treat the large number of these diseases. The committee also was charged to consider how the development of research and therapeutics might be fostered. This task proved to be daunting in a number of respects. Each rare disease has its particular unmet needs, and these may not even have been documented for hundreds if not thousands xi

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xii PREFACE of extremely rare conditions. Relatively few efforts have successfully ad- dressed scientific or technical questions across a spectrum of rare diseases. Furthermore, incentives for pharmaceutical, biotechnology, and medical device companies, starting with the Orphan Drug Act in 1983, to invest in the development of new diagnostics, therapeutics, and preventive interven- tions for rare diseases have had a limited impact on the gap between needs and effective responses. As documented in this report, opportunities now exist to accelerate progress toward understanding the basis for many more rare diseases and for developing innovative medical approaches. For example, the genomic era some 20 years ago promised when it was launched to unravel the mys- teries of genetic contributions to disease. Estimates that 80 percent or more of rare diseases have a genetic cause provided hope for many that solutions to their health problems might be around the corner. However, much of the initial effort to understand the genetic basis of disease was understandably focused on more common problems. It has, however, become increasingly evident that many common diseases have a very complex genetic basis that is taking much longer to map than was originally expected. Because many rare conditions stem from defects in a single gene, they offer opportunities for faster progress, especially given scientific and technological advances that identify the genetic basis of rare diseases and find molecular targets for the development of new treatments for these diseases. Thus, we are poised to make rapid advances in the understanding and, in an increasing number of cases, the treatment of rare diseases. As past research has demonstrated, some of these advances will undoubtedly illuminate disease mechanisms and treatment avenues for more common conditions. At the same time, many obstacles still complicate efforts to accelerate rare diseases research and product development. Regulatory efforts to ensure the safety and efficacy of new products for rare diseases need attention so that they do not impose avoidable delays or apply inappropriate standards in the evaluation of products for rare conditions. Funding for research for many rare diseases has lagged and lacked coordination, and investigators interested in pursuing research on rare diseases face many obstacles related not just to the availability of funding but to the mechanisms under which research grants are awarded. Furthermore, the cost of drug development under current models and the high costs of new drugs for rare conditions raise questions about whether it is time to create alternative pathways for drug development, including public-private partnerships. For these reasons, the committee came to the conclusion that a more coordinated national, and ideally global, effort to plan and begin system- atically to implement new strategies for addressing the needs of patients with rare diseases is a timely consideration. Leadership of this planning and implementation effort, as well as mechanisms to sustain the effort

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xiii PREFACE over time, present formidable challenges but are not insurmountable with the commitment of patients and families, advocacy groups, policy makers, companies, investigators, and others. The committee is hopeful that its efforts will catalyze thought and action that will benefit millions of our citizens with rare diseases and thereby contribute to the overall health of the nation. As chair of the committee, I acknowledge the strong contributions of two groups. The committee members quickly created an effective team and gave generously of their time and expertise for committee meetings, phone calls, and writing and review assignments. The Institute of Medicine staff brought together the myriad and disparate inputs and assembled them in a lengthy and complex report. The report would not have materialized with- out the persistent gentle prodding and guidance of our study director, Dr. Marilyn Field. Without her insistence on documentation of report elements to ensure that the report’s content and presentation met the highest stan- dards under a very ambitious time line, the multifaceted and interdependent dimensions of the committee’s charge could not have been so thoughtfully addressed. Thomas F. Boat, Chair Committee on Accelerating Rare Diseases Research and Orphan Product Development

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Contents SUMMARY 1 1 INTRODUCTION 15 Overview of Rare Diseases Research and Product Development: Challenges and Opportunities, 19 Historical and Policy Context, 22 Study Origins and Focus, 30 Concepts and Definitions, 32 2 PROFILE OF RARE DISEASES 41 Epidemiology of Rare Diseases, 43 Causes of Rare Diseases, 51 Prevention, Diagnosis, and Treatment, 55 Impact of Rare Diseases on Patients, Families, and Communities, 69 3 REGULATORY FRAMEWORK FOR DRUGS FOR RARE DISEASES 73 General Framework for the Regulation of Drugs and Biologics, 75 Regulatory Policy to Promote Innovation and Development of Orphan Drugs and Biologics, 85 FDA Resources and Organization, 101 Recommendations, 105 xv

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xvi CONTENTS 4 DISCOVERY RESEARCH FOR RARE DISEASES AND ORPHAN PRODUCT DEVELOPMENT 111 Target Discovery, 114 Therapeutics Discovery, 118 Infrastructure for Basic Research and Drug Discovery for Rare Diseases, 125 Innovation Platforms for Target and Drug Discovery, 137 Recommendations, 142 5 DEVELOPMENT OF NEW THERAPEUTIC DRUGS AND BIOLOGICS FOR RARE DISEASES 147 Preclinical Development, 149 Phase I Clinical Trials: Safety, 152 Phase II Clinical Trials: Proof of Concept or Efficacy, 154 Phase III Clinical Trials: Regulatory Proof, 154 Phase IV Postmarketing Studies, 156 Infrastructure for Drug Development, 156 Innovation Platforms for Drug Development, 165 Recommendations, 173 6 COVERAGE AND REIMBURSEMENT: INCENTIVES AND DISINCENTIVES FOR PRODUCT DEVELOPMENT 179 Medicare and Medicaid Coverage of FDA-Approved Drugs, 184 Private Health Plan Coverage of FDA-Approved Drugs, 197 Other Means of Financial Access to Orphan Drugs, 198 Public and Private Health Plan Coverage of Certain Costs in Clinical Trials, 200 Recommendations, 201 7 MEDICAL DEVICES: RESEARCH AND DEVELOPMENT FOR RARE DISEASES 205 Differences Between Medical Devices and Drugs, 206 Regulation of Medical Devices, 209 Coverage and Reimbursement for HDE Medical Devices, 224 Medical Device Research and Development, 225 Device Innovation and the HDE Option, 234 Recommendations, 237 8 TOWARD AN INTEGRATED APPROACH TO ACCELERATING RESEARCH AND PRODUCT DEVELOPMENT FOR RARE DISEASES 241 Elements of an Integrated National Strategy, 242 Recommendation, 246

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xvii CONTENTS REFERENCES 249 APPENDIXES A Study Activities 283 B Innovation and the Orphan Drug Act, 1983-2009: Regulatory and Clinical Characteristics of Approved Orphan Drugs 291 C Medicare Part D Coverage and Reimbursement of Orphan Drugs 309 D Glossary, Abbreviations, and Public Laws 345 E Rare Diseases Clinical Research Network 365 F Advocacy Group Approaches to Accelerating Research and Product Development: Illustrative Examples 371 G Committee and Staff Biographies 387 INDEX 395

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Boxes, Figures, and Tables BOXES S-1 Elements of an Integrated National Strategy to Accelerate Research and Product Development for Rare Diseases, 3 1-1 Examples of Rare Diseases, 17 1-2 Elements of an Integrated National Strategy to Accelerate Research and Product Development for Rare Diseases, 18 1-3 Organized Research on Exceptionally Rare Diseases Is Possible, 22 1-4 Examples of Ongoing Reporting of New Rare Syndromes in Orphanet Newsletter, 35 1-5 Rare by Genotype or Rare by Phenotype: The Example of Hemochromatosis, 36 1-6 Types of Clinical Trials, 39 3-1 Options for Patients to Obtain Access to Investigational Drugs When the Primary Purpose Is to Diagnose, Monitor, or Treat a Patient’s Disease or Condition, 80 3-2 Primary Incentives Provided by the Orphan Drug Act, 87 3-3 Examples of Variations in Types of Efficacy Studies Accepted by FDA in Orphan Drug Approvals, 96 3-4 Examples of Problem Areas for Sponsors Developing Evidence for Orphan Drug Approval, 99 3-5 NIH Request for Applications on Advancing Regulatory Science Through Novel Research and Science-Based Technologies (Febru- ary 24, 2010), 103 xix

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xx BOXES, FIGURES, AND TABLES 4-1 Examples of Research on Rare Diseases with Implications for Treatment of Common Conditions, 113 4-2 Improving Rare Disease Diagnostics: Enabling Technologies, 124 5-1 Summary of Earlier IOM Report Recommendations for Effective Biomarker Evaluation, 158 5-2 Examples of Initiatives to Increase Information About Clinical Trials and FDA or Company Decisions About Products, 166 7-1 Examples of Devices Approved Under the Humanitarian Device Exemption, 221 7-2 Expectations for Consortia to Stimulate Pediatric Device Devel- opment, 223 7-3 Stanford University Biodesign Program, 230 7-4 Innovations in Engineering and Biological Sciences and Medical Device Innovation, 232 FIGURES 2-1A Number of rare diseases by prevalence up to 50/100,000, 49 2-1B Number of rare diseases by prevalence of 10/100,000 or less, 49 2-1C Number of rare diseases by number of individual cases in literature, 50 2-1D Number of rare diseases by number of family cases in literature, 50 4-1 Plot of NIH grants for illustrative rare diseases by disease preva- lence, 131 5-1 Drug development: from idea to market, 148 7-1 Total product life cycle for medical devices, 227 B-1 Annual orphan drug approvals by “newness,” 304 TABLES 1-1 Time Line of Selected Events Relevant to Policies Promot- ing Research and Development for Rare Diseases and Orphan Products, 24 1-2 Funding for Biomedical Research in the United States by Source, 2007, 28 1-3 Comparison of Selected National Policy Incentives for Orphan Drug Development, 30

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xxi BOXES, FIGURES, AND TABLES 1-4 Prevalence Criteria for the Definition of Rare Disease in Selected Countries, 33 2-1 Differences in Prevalence for Three Cancers with Similar Numbers of New Cases per Year but Different Survival Rates, 2006, 47 2-2 Examples of Currently Available Treatments or Treatments in Development for Rare Diseases, 63 2-3 Characteristics of Child and Adolescent Health That May Affect the Complexity of Health Care Transitions, 68 4-1 Active NIH Awards for Four Rare Diseases by Number, Funding Total, and Type as of April 2010, 132 6-1 Coverage of Part D-Eligible Drugs by Type of Medicare Prescrip- tion Drug Plan, 195 7-1 Complex Medical Devices Tend to Differ from Drugs, 208 7-2 Incentive Comparison: Drugs or Biologics Versus Devices, 217 B-1 Orphan Approvals for Somatropin Products, 299 C-1 Average Premium and Use of Deductible for Different Types of Medicare Prescription Drug Plans, 316 C-2 Orphan Drug Coverage by Type of Medicare Prescription Drug Plan, 317 C-3 Orphan Drugs with No, Very Low, or Low Plan Coverage, 318 C-4 Orphan Drugs by Rate of Tier 4 Placement and Type of Medicare Prescription Drug Plan, 320 C-5 Orphan Drugs by Rate of Prior Authorization Use and Type of Medicare Prescription Drug Plan, 320 C-A1 Orphan Drugs Relevant to Medicare Population, 323 C-A2 Medicare Stand-Alone PDP Coverage of Orphan Drugs: Inclusion on Formulary (i.e., Plan Coverage), Tier Placement, and Utiliza- tion Management, 332 C-A3 Drugs with a Pediatric Orphan Indication, 338 C-A4 Medicare Stand-Alone PDP Coverage for Drugs with a Pediatric Orphan Indication: Inclusion on Formulary (i.e., Plan Coverage), Tier Placement, and Utilization Management, 341 F-1 Spending on Research or Research Grants for Selected Advocacy Organizations, 2008, 373

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