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Radar On Market Access: Copay Accumulators’ Use Rises; Virginia Passes Law Banning Such Programs

April 23, 2019

Payers are continuing to implement copay accumulators and copay maximizers in an effort to counter copay assistance from pharmaceutical manufacturers, according to a recent survey, AIS Health reported.

Payers are continuing to implement copay accumulators and copay maximizers in an effort to counter copay assistance from pharmaceutical manufacturers, according to a recent survey, AIS Health reported.

A Zitter Insights report shows that more than 90 million commercial lives are covered by payers that have a copay accumulator program — and it doesn’t look like these arrangements are going away any time soon.

It also explores the use of a similar kind of program: copay maximizers. Among 51 payer respondents covering 177.9 million lives, payers covering more than 50 million commercial lives have implemented a copay maximizer program. But payers representing 58% of covered lives say they do not have plans to incorporate maximizers within their benefits offerings.

Melinda Haren, a senior consultant at Zitter Insights, notes that accumulators and maximizers are focused on specialty drugs, particularly those products that are adjudicated through the pharmacy benefit.

The savings for payers — and the additional burden on manufacturers — are not insignificant. But drugmakers can do little to limit the use of these programs, at least in the short term, says Haren.

One recent effort may prove to be effective against accumulators: On March 21, Virginia Gov. Ralph Northam (D) signed a law that will go into effect Jan. 1, 2020, which states, in part, “When calculating an enrollee’s overall contribution to any out-of-pocket maximum, deductible, copayment, coinsurance, or other cost-sharing requirement under a health plan, a carrier shall include any amounts paid by the enrollee or paid on behalf of the enrollee by another person.”

This approach to counter accumulators “will likely be effective, at least in the near term,” maintains Jeremy Schafer, Pharm.D., senior vice president of payer access solutions at Precision for Value.

2019 Specialty Pharmacy Patient Choice Awards Finalists Announced

April 23, 2019

patient choice awards - video and badge - zitter mmit

The Specialty Pharmacy Patient Choice Award was created to recognize specialty pharmacies and their commitment to patient satisfaction. The criteria for this award were formulated by a committee comprised of individuals representing pharmaceutical manufacturers, health plans, pharmacy benefit managers (PBMs), trade organizations, consultants and equity research firms.

Rankings for the Patient Choice Awards are based on these organizations’ average Net Promoter Score from quarterly Zitter Insights Specialty Pharmacy Patient Satisfaction Surveys.

patient choice awards - video and badge - zitter mmit

The Specialty Pharmacy Patient Choice Award was created to recognize specialty pharmacies and their commitment to patient satisfaction. The criteria for this award were formulated by a committee comprised of individuals representing pharmaceutical manufacturers, health plans, pharmacy benefit managers (PBMs), trade organizations, consultants and equity research firms.

Rankings for the Patient Choice Awards are based on these organizations’ average Net Promoter Score from quarterly Zitter Insights Specialty Pharmacy Patient Satisfaction Surveys. Finalists for this annual award are selected for achieving the highest patient satisfaction scores in one of two categories: A) PBM/Payer Specialty Pharmacy or B) Non-PBM/Payer Specialty Pharmacy.

The team at Zitter Insights, which is now a part of MMIT, the industry standard in formulary, policy and restriction data, is proud to announce the finalists for the 2019 Patient Choice Awards:

The winner in each category will be announced during the Patient Choice Awards in the fall of 2019. Additional information on the event will be distributed later in the year.

A core element of MMIT’s philosophy is recognizing industry leaders who help to simplify complex healthcare challenges – in this case, specialty pharmacies. In this same vein, the organization will continue to heavily invest in the Specialty Pharmacy Patient Choice Awards and bring awareness to the outstanding performance of the organizations who lead this industry into the future of healthcare.

MMIT Reality Check on Ophthalmic Anti-Inflammatory (Apr 2019)

April 19, 2019

According to our recent payer coverage analysis for ophthalmic anti-Inflammatory treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

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To help make sense of this new research, MMIT’s team of experts analyzes the data and summarizes the key findings for you. The following are brief highlights. To read the full piece, including payer coverage, drug competition and prescriber trends, click here.

Payer Coverage: A review of market access for ophthalmic anti-Inflammatory treatments shows that under the pharmacy benefit, almost 64% and 42% of the lives under commercial formularies and Medicare formularies are covered without utilization management restrictions, respectively.

Trends: There are numerous products in the ophthalmic anti-inflammatory pipeline; many are new formulations or strengths of the same chemical entity, while only one is a new molecule. Via AIS Health.

Perspectives on Insulin Management

April 18, 2019

Amid increasing public scrutiny of rising insulin prices, some health insurers are taking matters into their own hands to help their diabetic members afford the lifesaving medications, AIS Health reported.

Amid increasing public scrutiny of rising insulin prices, some health insurers are taking matters into their own hands to help their diabetic members afford the lifesaving medications, AIS Health reported.

At the integrated health system HealthPartners, the members who are hardest hit by rising insulin prices are those in high-deductible health plans, says Young Fried, vice president of pharmacy plan services. But she says insulin affordability is also an issue for Medicare members who are in the Part D “doughnut hole.”

One tactic that the organization’s health plan deploys to ease the burden on members is a policy called “plan pay the difference,” Fried says. If a brand drug becomes cheaper than the generic version after rebates, “we would actually have the member pay the generic copay instead of the brand, and then we would reimburse the pharmacy the brand cost, so that they’re made whole as well,” she says.

At Geisinger Health Plan, Medicare enrollees are the ones who have the most trouble paying for their insulin, according to Jamie Miller, the health plan’s system director of managed care pharmacy. Overall, Geisinger saw its spending in the diabetes drug class rise 13.8% between 2017 and 2018, she adds.

As Geisinger works out what it wants its Medicare benefit to look like in 2020, Miller says one goal is to make insulin more affordable for its senior members. Thus, the health plan is considering adding a sixth, “zero-dollar” tier to its Part D formulary where it would put insulin and select other drugs.

Radar On Market Access: CMS Finalizes Medicare Rates, Unveils ’20 Opioid Policies

April 18, 2019

CMS recently released its annual payment information and policy updates for Medicare Advantage, MA Prescription Drug (MA-PD) and stand-alone Prescription Drug Plans, underscoring the need for a better approach to opioid monitoring and management, AIS Health reported.

CMS recently released its annual payment information and policy updates for Medicare Advantage, MA Prescription Drug (MA-PD) and stand-alone Prescription Drug Plans, underscoring the need for a better approach to opioid monitoring and management, AIS Health reported.

Yet overall, industry experts say perhaps the most eye-catching features of CMS’s 2020 MA and Part D Rate Announcement and final Call Letter are the better-than-anticipated pay rate and the lack of worrisome new mandates, policy changes or major technical issues.

By incorporating an underlying “coding trend,” which CMS says will boost risk scores by 3.3%, on average, MA plans likely will see somewhere in the neighborhood of a 5.5% rate hike on average year over year, says Tim Courtney, director and senior consulting actuary of Wakely Consulting LLC.

“There just weren’t a lot of notable, earth-shaking changes this year [for the Part D program], which is good,” says Wayne Miller, R.Ph., vice president of pharmacy solutions for Gorman Health Group LLC.

“I think there’s more change coming in the [Medicare quality] star ratings measures being implemented around the opioids,” he adds, pointing to CMS’s addition of a 2020 display measure on how plans manage members’ use of opioids at higher dosages.

The agency in its 2020 final Call Letter urges Medicare plans to take voluntary steps to improve drug utilization review controls for opioids. It also says that it is “encouraging” Part D plan sponsors “to include at least one naloxone product on a generic or Select Care Tier.”