Datapoint

Minnesota’s state legislature last week passed legislation that will establish public option health insurance in the state by 2027, joining Colorado, Washington and Nevada in similar efforts. Next year, the state will conduct an actuarial analysis on the initiative, which would serve as an expansion of MinnesotaCare, a state health plan for people living below 200% of the federal poverty line. Payer groups such as AHIP and Minnesota-based health systems have rallied against the proposal. The three largest payers in Minnesota are Blue Cross and Blue Shield of Minnesota (2,166,301 members), the provider-sponsored insurer HealthPartners (903,759 members) and nonprofit insurer Medica (663,434 members).

Boston-based health system Tufts Medicine has joined Blue Cross Blue Shield of Massachusetts’ pay-for-equity financial payment model that launched earlier this year, according to a May 23 press release. The arrangement, the first of its kind in Massachusetts, seeks to address health inequities and decrease racial gaps in health care. The Blues insurer said with the addition of Tufts, 53% of its members are now receiving care from providers within the initiative. Blue Cross Blue Shield of Massachusetts is the largest insurer in its home state, serving 2,229,079 members. About 38% of its members are enrolled in commercial risk-based products, with an additional 58% served via self-funded arrangements with employer groups.

The FDA on May 18 approved AbbVie’s Rinvoq for the treatment of moderately to severely active Crohn’s disease in adult patients who have had an inadequate response or intolerance to at least one TNF blocker. The nod becomes the JAK inhibitor’s second approval in gastroenterology, and its seventh overall. Rinvoq will also be the first JAK inhibitor in the Crohn’s market basket. The drug was first approved in 2019 for the treatment of moderate-to-severe rheumatoid arthritis, an indication for which it currently holds covered or better status for 96% of all insured lives in the U.S. About 63% of insured lives have preferred access to Rinvoq, largely with utilization management restrictions applied. Rinvoq was AbbVie’s sixth best-selling drug worldwide in 2022, bringing in $2.52 billion in sales, according to Evaluate Pharma. Evaluate projects the JAK inhibitor will be AbbVie’s No. 2 bestseller by 2025.

The United States Supreme Court on May 18 ended a long-running patent dispute between Amgen, Sanofi and Regeneron over the drugmakers’ PCSK9 inhibitors. Justices upheld a 2019 lower court ruling, which stated that Amgen could not make patent claims over monoclonal antibodies without more thoroughly describing their molecular structure, a decision that could have wider implications for the pharmaceutical industry as a whole. Praluent and Repatha are both approved to treat three forms of high low-density lipoprotein cholesterol (LDL-C); heterozygous familial hypercholesterolemia (HeFH), atherosclerotic cardiovascular disease (ASCVD), and homozygous familial hypercholesterolemia (HoFH). Under the pharmacy benefit, Repatha SureClick holds covered or better status for 82% of all insured lives, to Praluent Pen’s 71%.

Oscar Health will exit the California Affordable Care Act exchange market, Covered California, for the 2024 plan year, executives revealed during the insurance startup’s first-quarter 2023 earnings call. The California exit is part of a push toward profitability, as the plan “has not met our targets,” CEO Mark Bertolini said during the call. Oscar is currently the seventh-largest exchange insurer in the state, serving 44,658 members. Oscar is the fourth-largest exchange insurer nationally, with 977,408 members.

Sentara Healthcare, a Norfolk, Va.-based nonprofit health systems of 14 hospitals that also operates a health insurer, said it will combine its Medicaid products into a single plan. The two plans, Virginia Premier and Optima Health, will be united under the Optima Health name beginning July 1. “[This] will enable us to continue to provide a superior customer experience for our Medicaid membership — while also creating efficiencies that support lower costs for the state and reduced administrative burden on health care providers, Colin Drozdowski, president of Sentara Health Plans, said in a May 10 press release. Virginia Premier’s dual eligible Special Needs Plan will continue to operate as Virginia Premier. Virginia Premier currently enrolls 318,705 Medicaid and CHIP members to Optima Health’s 314,982. Sentara is the largest managed Medicaid insurer in Virginia.

The FDA on May 10 approved Otsuka and Lundbeck’s Rexulti for the treatment of agitation associated with dementia due to Alzheimer’s disease, making it the first and only therapy available for that indication. Agitation is one of the “most complex and stressful aspects of caring for people” with Alzheimer’s dementia, and occurs in about 50% of patients, Otsuka noted in a press release. The second-generation oral antipsychotic was first approved to treat major depressive disorder and schizophrenia in 2015. For those indications, Rexulti currently holds covered or better status for 92% of all insured lives under the pharmacy benefit. Coverage requires prior authorization and/or step therapy for about 43% of insured lives.

Humana Inc. is partnering with Longevity Health, a clinical services company and national Institutional Special Needs (I-SNP) plan, on new I-SNP offerings in Georgia and South Carolina. These SNPs are “designed to materially improve health outcomes through holistic, patient-centric care plans,” according to a May 4 press release. Following the initial launch, the partnership with expand to five more states in 2024, with more geographies to come in 2025. Plan benefits will include onsite clinicians dedicated to comprehensive care management, $0 copays for primary care and behavioral health visits, transportation to medical appointments and hearing aid coverage. Longevity currently enrolls 4,768 members in its I-SNP plans in seven states. Humana, meanwhile, enrolls 829,093 members in Special Needs Plans nationwide.

Regeneron’s blockbuster eye drug Eylea saw U.S. sales fall to $1.43 billion in the first quarter of 2023, a 5% decrease from the previous quarter, and its second consecutive quarterly decline. Roche’s new-to-market Vabysmo — a rising competitor to Eylea — saw global sales jump 40% to $486 million in the same time period. Evaluate Pharma projects Vabysmo will bring in $1.5 billion in global sales by the end of 2023 and become the drugmaker’s fifth best-selling product in 2024. The FDA on May 9, meanwhile, accepted an application for Vabysmo to treat retinal vein occlusion, another Eylea stronghold. For the treatment of wet age-related macular degeneration, Vabysmo currently holds covered or better status for 80% of all insured lives under the medical benefit, to Eylea’s 97%.

House Republicans on April 26 passed debt-ceiling legislation that reintroduced Medicaid work requirements — a controversial Medicaid reform that was adopted by several states during the Trump administration — at the federal level. A new analysis from KFF, meanwhile, predicts that House Republicans’ Medicaid work requirements proposal would leave 1.7 million enrollees ineligible for Medicaid. Under the proposal, states could continue to cover enrollees who violate the work requirement, but they would have to cover 100% of their costs without federal help, which could ultimately shift $10.3 billion in spending to state governments, KFF projected. As of April 2023, 95.6 million people currently receive Medicaid benefits, a 29.6% increase from the outset of the COVID-19 pandemic in March 2020.