Milestone Pharmaceuticals (MIST) Q2 FY26 earnings call: guidance and Q&A

What percentage of the 600 new Q2 prescribers were high-volume vs. one-time writers, and how is the mix between cardiologists, electrophysiologists, and nurse practitioners shifting?

Many Q2 writers were one-timers, but this is seen as a strength, indicating broad initial adoption. Electrophysiologists are prescribing more than expected. The company plans to increase call frequency for early adopters to drive depth of prescribing, while continuing to expand breadth.

“You know, we always expected EPs to treat these patients, but we didn't expect them to write as early and as broadly because, you know, let's face it, their job is to do ablations, right? And so we always expected some use, but we're seeing, I think, more than we even expected, which I think is an early sign of, you know, a good sign for the market where we've got the thought leaders that are getting experience and then going to be advocating for it.”

asked by Athena Chan · answered by Joseph Oliveto

Commentary on pricing, gross-to-net discounting, and early indications on repeat use to inform annual attack rate numbers.

Initial strategy involved significant copay mitigation and denial conversion due to low commercial coverage, impacting average selling price. With recent coverage expansion to 50%, denial conversion is expected to decrease, improving gross-to-net. Repeat use is starting to be observed, with 1,500 scripts for 1,300 patients in H1, aligning with clinical trial expectations.

“As a result of that, our strategy was to allow for a fair amount of copay mitigation. And when you don't have a lot of coverage, that means a lot of denial conversion, meaning that, you know, the script is basically given away and we don't make any revenues from it. So that really swamps out your average selling price over that period while coverage is low.”

asked by Ted Tenthoff · answered by Joseph Oliveto

Clarify the difference between 25% commercial covered lives and total covered lives, and whether current rebates are in line with expectations.

PSVT population is roughly 45% commercial, 45% Medicare, 10% other. Commercial coverage is expected to come sooner. Rebates for the initial coverage (now >50% commercial) are in the ballpark of what was expected, allowing for good coverage and reasonable patient out-of-pockets.

“Essentially, SVT is about half of our population is under 65, and about half of our population is over 65. When that breaks down into coverage, it's actually, to be very specific, a little bit more like 45% commercial, 45% Medicare, and about 10% other...”

asked by Mohit Bansal · answered by Joseph Oliveto

How will improved commercial coverage translate to prescription volume and net revenue per patient? What are the remaining risks for the ReVeRA AFib trial, given the sNDA pathway and similar formulation?

Improved coverage will primarily boost revenues by reducing denial conversion and improving gross-to-net. It will also increase scripts as physicians perceive easier access and less paperwork. For ReVeRA, key risks are the criticality of the patient-reported outcome (secondary endpoint) and managing patient misdiagnosis of events, which was observed in PSVT trials. These are incorporated into study powering.

“The first one being that the secondary endpoint is pivotal to getting the approval, and that is a patient-reported outcome... The other difference between, I would say, the AFib-RVR program and the SVT program is those patients that misdiagnose their event.”

asked by Tiago Fauth · answered by Joseph Oliveto

Are prescribers conducting 'mini patient experience trials' before broader use? What is the physician targeting strategy for H2 2026 and 2027, focusing on breadth vs. depth?

Some physicians do wait for initial patient experience before broader prescribing, but many early adopters prescribe broadly. The strategy for H2 involves both breadth (identifying new targets) and depth (increasing call frequency for early adopters to drive consistent use and higher volume).

“So the bottom line is we're doing both breadth and depth right now... we're doing a very targeted digital marketing campaign that involves advertising to patients where they are, whether it's social media or search or even banner advertising on things like WebMD and other resources, so that we get the patient's attention there.”

asked by Brandon Folkes · answered by Joseph Oliveto

How much of the H2 acceleration expectation is from improved coverage vs. patient awareness? Details on patient activities and expected impact. How quickly will commercial coverage scale from 50%?

H2 acceleration is a gestalt of improved coverage, refined sales/marketing, and new patient activation. Patient activation was gated by coverage, now at >50% commercial. It involves targeted digital marketing (not DTC TV ads) to drive patients to Cardamyst.com for education and resources, encouraging them to ask their doctors. The company is bullish on continued coverage growth but cannot predict exact timing.

“What we did not want to do was start driving patient awareness and ask patients to go into their doctors and ask about Cardamyst if coverage wasn't approaching some critical mass, which we feel at least 50% of commercial coverage gives us that chip to be able to go in and start that.”

asked by Georgia Bank · answered by Joseph Oliveto