MMIT brings transparency and guidance to pharmacy and medical benefit information

Manage with confidence. Decide with information. Communicate with certainty.
MMIT

MMIT Reality Check on Epilepsy (Jan 2020)

January 24, 2020

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

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

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 epilepsy treatments shows that under the pharmacy benefit, almost 31% of the lives under commercial formularies are covered with utilization management restrictions.

Trends: In January 2020, the FDA approved Neurelis, Inc.’s Valtoco (diazepam nasal spray) as an acute treatment of intermittent, stereotypic episodes of frequent seizure activity that are different from usual seizure patterns in people at least 6 years old with epilepsy.

Perspectives on MA Supplemental Benefits

January 23, 2020

Despite Medicare Advantage insurers’ enthusiasm for increased flexibility in allowable supplemental benefits and a slew of recent plan press releases touting goodies such as pest control and “Papa Pals” for the 2020 plan year, uptake of more “resource intensive” benefits geared toward seriously ill seniors remains relatively modest, according to a new report from the Duke Margolis Center for Health Policy.

Despite Medicare Advantage insurers’ enthusiasm for increased flexibility in allowable supplemental benefits and a slew of recent plan press releases touting goodies such as pest control and “Papa Pals” for the 2020 plan year, uptake of more “resource intensive” benefits geared toward seriously ill seniors remains relatively modest, according to a new report from the Duke Margolis Center for Health Policy.

The December report, “Improving Serious Illness Care in Medicare Advantage: New Regulatory Flexibility for Supplemental Benefits,” showed that a total of 507 standard MA plans in 2019 offered one of five types of benefits addressing serious illness, accounting for roughly 11% of the approximately 4,500 standard MA plans in 2019, AIS Health reported. By contrast, 377 in 2020 offered at least one of the five benefits highlighted in the report, while no plans in 2019 offered more than one of these benefits. But that drop was mainly driven by one major carrier abandoning its caregiver support benefit for 2020. Meanwhile, about 175 plans offered at least two of these types of these benefits, according to Robert Saunders, research director and one of the report’s authors.

Despite the decrease in caregiver support, which had the greatest initial uptake of the five benefit categories in 2019, researchers saw meaningful increases for 2020 in benefits such as adult day care and palliative care that “more directly address the needs of members with serious illness.”

The study also linked the PBP data to MA enrollment figures by plan and by county to assess the geographic impacts of the policy changes. For 2020, many parts of the country do not have any plans offering new supplemental benefits, and those aimed at serious care were likely to be offered in urban counties, said the report.

Barring any major disruption, 2021 will likely be the year of growth for new flexible benefits, as it takes plans a couple years to price, test and stand up ones that will have a lasting impact, adds Saunders.

Radar on Market Access: Supreme Court to Determine States’ Ability to Regulate PBMs

January 23, 2020

The Supreme Court has agreed to hear a case that observers say ultimately could upend state-based efforts to regulate PBMs and potentially even lead to legislation on the federal level to rein them in, AIS Health reported. The lawsuit, which was brought by the Pharmaceutical Care Management Association, challenges a 2015 Arkansas law that requires PBMs to reimburse pharmacies at or above their wholesale cost for generic drugs.

The Supreme Court has agreed to hear a case that observers say ultimately could upend state-based efforts to regulate PBMs and potentially even lead to legislation on the federal level to rein them in, AIS Health reported. The lawsuit, which was brought by the Pharmaceutical Care Management Association, challenges a 2015 Arkansas law that requires PBMs to reimburse pharmacies at or above their wholesale cost for generic drugs.

The case boils down to whether PBMs are acting as agents under the Employee Retirement Income Security Act of 1974 (ERISA) and therefore are exempt from state-level regulation, or whether they are a “non-interested party and therefore subject to regulation,” says Jeff Myers, founder of health care consulting firm OptDis. He says that he believes it’s likely the high court justices will side with PCMA and the PBM industry, agreeing that ERISA bars state laws like the one at issue in Arkansas.

“If the Supreme Court were to say states have the ability to regulate the PBM marketplace inside ERISA plans…it would give states an almost unlimited ability to force payers to pay a rate [to pharmacies] they deem sufficient,” Myers says. Independent pharmacy lobbies generally are quite powerful in states, and would demand higher rates, he says, adding that this would lead to higher drug prices overall.

If the Supreme Court rules that states can’t directly regulate PBMs, he adds, states may try to regulate them via insurers instead, and “stop attacking PBMs directly.” He says this is the more likely scenario, and something the nine justices could be keeping in mind as they consider this case.

“If the PBMs win, the precedent it sets is that states have no ability to control” them under ERISA plans, Myers says. “The only way you can do it is by going to the actual payer and saying, ‘This is a requirement for offering insurance in my state.'”

Radar on Market Access: Kansas Works Out Medicaid Expansion Deal

January 21, 2020

Kansas Gov. Laura Kelly (D) and Republican Senate Majority Leader Jim Denning on Jan. 9 said they’d reached a compromise proposal to extend Medicaid coverage to an estimated 130,000 more low-income Kansans, AIS Health reported.

Kansas Gov. Laura Kelly (D) and Republican Senate Majority Leader Jim Denning on Jan. 9 said they’d reached a compromise proposal to extend Medicaid coverage to an estimated 130,000 more low-income Kansans, AIS Health reported.

If approved, Kansas will pursue a full expansion of Medicaid to 138% of the Federal Poverty Level (FPL) with a 90/10 funding match. The state will also seek Section 1332 waiver approval to establish a reinsurance program and Section 1115 waiver approval to transition individuals whose incomes fall between 100% and 138% of the FPL from Medicaid to the exchange no later than Jan. 1, 2022, although expansion is not dependent on those waivers. If CMS denies either waiver, full Medicaid expansion will be implemented on Jan. 1, 2021, according to a summary of the pending legislation.

Kansas would be the 37th state to expand Medicaid. Ballot initiatives are pending in Missouri and Oklahoma, while voters in Nebraska and Utah have already approved expansion. The 10 remaining non-expansion states are largely concentrated in the South.

According to a summary of the pending Kansas legislation, the compromise proposal would feature a “robust work referral program,” “modest” premiums of up to $25 per month for an individual (or $100 per family) and no lockout provisions. But the expansion deal does not include work requirements.

Compared with other states that have attempted to require able-bodied expansion enrollees to seek work or other volunteer activities or risk losing their Medicaid coverage, the Kansas tactic is “a kinder, gentler approach to work,” remarks Jerry Vitti, founder and CEO of Healthcare Financial, Inc.

In a Jan. 9 research note from Evercore ISI, securities analyst Michael Newshel noted that if the approximately 130,000 additional lives that would be covered by expansion were split evenly among the state’s three contracted MCOs — which are units of Centene Corp., CVS Health Corp.-owned Aetna and UnitedHealthcare — they would each gain roughly $250 million in annual revenues.

MMIT Reality Check on Prostate Cancer (Jan 2020)

January 17, 2020

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

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

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 prostate cancer treatments shows that under the pharmacy benefit, almost half of the lives under commercial formularies are covered with utilization management restrictions.

Trends: In December 2019, the FDA granted another indication to Xtandi (enzalutamide) for the treatment of men with metastatic castrationsensitive prostate cancer.