RADAR on Drug Benefits

With Prescriber Interventions, Highmark Reduces Risky Opioid Use Among Members

The opioid epidemic — which by one measure peaked in 2017, when the Centers for Disease Control and Prevention (CDC) recorded 17,029 U.S. deaths involving prescription opioids — is far from over. In fact, CDC data show that deaths tied to prescription opioids, after declining in 2018 and 2019, came roaring back with the onset of the COVID-19 pandemic, and totaled 16,416 in 2020.

As the country continues to grapple with this stubborn issue, health insurers have learned they have a role to play in helping stop would-be opioid use disorder cases where many originate: with well-meaning doctors poised to write out a prescription. One such insurer is Pittsburgh-based Highmark, which is engaged in a multiyear partnership with a company called Wayspring to track providers’ prescribing habits and reach out to educate those who appear to deviate from the CDC’s recently updated clinical practice guidelines for prescribing opioids for pain.

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News Briefs: Optum to Include Humira Biosimilars in Formulary

UnitedHealth Group's Optum Rx PBM said that it will incorporate as many as three new biosimilars in its formulary to compete with AbbVie Inc.'s Humira, the immunosuppressant biologic that consistently is the most costly drug to the U.S. health care system. However, Optum will still cover Humira: it will be placed on the same tier as the new biosimilars. According to Optum, the company spends at least $20 billion on Humira every year, according to Bloomberg.

Merck & Co. Inc. will acquire Imago BioSciences Inc. for $1.35 billion, the companies said on Monday. Imago's lead product is "bomedemstat (IMG-7289), an investigational orally available lysine-specific demethylase 1 (LSD1) inhibitor, is currently being evaluated in multiple Phase 2 clinical trials for the treatment of essential thrombocythemia (ET), myelofibrosis (MF), and polycythemia vera (PV), in addition to other indications," according to a Merck press release. The purchase could shore up Merck's portfolio of treatments for blood and bone marrow cancers. At present, Bristol-Meyers Squibb Co. and a joint venture of Incyte Corp. and Novartis AG lead the market in those categories.

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Customer Satisfaction With PBMs Drops to a Three-Year Low, Study Reports

Plan sponsors’ overall satisfaction with their PBMs was 7.8 on a 1-10 scale in 2022, down from 8.2 last year, according to Pharmaceutical Strategies Group’s 2022 Pharmacy Benefit Manager Customer Satisfaction Report. The report was based on surveys completed by 236 individuals representing employers, unions/Taft Hartley plans, health plans and health systems that covered an estimated 76 million lives. Respondents reported a lower likelihood to recommend their PBM to a colleague or to renew their contract without issuing a competitive request for proposal this year, highlighting costs as the primary driver to leave the PBM.

Among core PBM services, satisfaction was highest for “offering competitive traditional drug discounts” and “meeting financial guarantees.” As clinical and cost management programs play a key role in reducing overall costs, 82% of respondents reported using utilization management, while only 8% used gene therapy financial protection programs.

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End of COVID Bump, Negative News May Have Dented PBM Satisfaction

Plan sponsors are reporting less satisfaction with their PBMs than they have in prior years, according to a recent survey. While industry experts differ regarding what may be driving that trend, they also have plenty of ideas about what PBMs — or failing that, their regulators — can do to improve how the industry performs.

The 2022 Pharmacy Benefit Manager Customer Satisfaction Report is the 25th annual version produced by the Pharmaceutical Strategies Group (PSG), an EPIC Health LLC subsidiary. In an Oct. 19 press release unveiling the findings, the organization wrote that “there was a notable downturn in overall satisfaction levels” with PBMs in this year’s survey, “as well as in some core measures of general satisfaction such as likelihood to recommend.” Measured on a scale of one to 10, plan sponsors’ overall satisfaction with PBMs was 7.8 in 2022, down from 8.2 last year — and at the lowest level it has been since 2016.

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As Debate Rages Over Copay Accumulators, State Bans Proliferate

The copay accumulator bans passed in 15 states affect about 15 million people, or 11% of U.S. commercial plan members, according to research by consulting firm Avalere Health. Experts say the drug manufacturer-backed bans pick winners between payers and patients, but don't come close to solving the persistent problem of sky-high prices for life-saving drugs.

Copay accumulators are the practice, implemented by PBMs, of preventing the value of copay assistance programs from counting toward a plan member's deductible and out-of-pocket maximum calculation. A related practice, copay maximizers, spreads out the value of a copay coupon over 12 months while also preventing that coupon from counting toward a patient’s deductible/out-of-pocket maximum. Fifteen states and Puerto Rico have banned these practices in fully funded plans, which states can regulate — self-insured plans, since they are regulated by the Employee Retirement Income Security Act, are not included.

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ICER Examines Cost Effectiveness, Clinical Effectiveness of Multiple Sclerosis Drugs

Three FDA-approved multiple sclerosis treatments and one MS drug that the FDA is currently reviewing are not cost effective, according to an analysis from the Institute for Clinical and Economic Review (ICER). Jon Campbell, Ph.D., ICER’s senior vice president for health economics and one of the report’s authors, also tells AIS Health that there was “insufficient evidence” to differentiate the clinical effectiveness of any of those four drugs, which are known as monoclonal antibodies.

The findings were part of a larger ICER draft evidence report published on Oct. 17 that examined the clinical effectiveness and cost effectiveness of oral and monoclonal antibody disease modifying therapies (DMTs) for relapsing-remitting MS. About 85% of the 1 million Americans with MS have the relapsing-remitting form.

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News Briefs: Pharma Execs Say Medicare Negotiation Will Dent Profits

Elevance Health, Inc. said on Nov. 9 that it has struck a deal with CarepathRx, a portfolio company of the private equity firm Nautic Partners, to acquire the specialty pharmacy BioPlus. The acquisition “helps us deliver on our whole-health strategy that gives our consumers improved access and reliability to their prescriptions when they need it most,” said Pete Haytaian, executive vice president of Elevance Health and president of its Carelon health services business. Elevance plans to “expand BioPlus’ speed and service models across more complex disease treatment areas to provide timely access to medication, deliver leading support services for both providers and patients, and ensure individuals receive distinctive clinical expertise and service at all levels of care,” it said in a press release. Given that BioPlus currently operates Centers of Excellence addressing therapeutic areas like oncology and multiple sclerosis, Elevance aims to “build out additional COEs” for other therapeutic areas once the specialty pharmacy becomes part of Elevance’s PBM, IngenioRx. The acquisition is subject to customary closing conditions and is expected to close in the first half of 2023.

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IngenioRx, Centene Contract Switch Take Spotlight in PBMs’ 3Q Earnings Calls

Although Centene Corp.’s decision to contract with Cigna Corp. rather than CVS Health Corp. for PBM services loomed large during major health insurers’ third-quarter earnings conference calls, it wasn’t the only PBM-related discussion worth noting.

For example, during Elevance Health, Inc.’s earnings call on Oct. 19, executives offered some insights about how the firm’s in-house PBM IngenioRx is carving out a niche in the marketplace.

“We are, as you know, trying to be a different PBM,” Peter Haytaian, Elevance’s president of Diversified Business and IngenioRx, said in response to an analyst’s question about the PBM’s progress selling its services to self-insured employers that already contract with Elevance.

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Report: Launch Prices of Oncology Drugs Have Gone Up 8,000%

The median launch price of oncology drugs increased by over 8,000% between 2008 and 2021, according to a new report compiled by the office of Rep. Katie Porter (D-Calif.), from $2,115 to $180,087. The report, which draws mainly on data from the FDA's Center for Drug Evaluation and Research (CDER), calls for reforms to the FDA approval process and Medicare’s market access rules in order to curb or unwind launch price growth, which have made oncology drugs unaffordable for many critically ill patients.

The report calls for reforms to launch price regulations, some of which could be implemented under existing FDA authority. It also examines how launch pricing dynamics may change as the federal government prepares to implement Medicare drug price negotiation — part of this year’s blockbuster Inflation Reduction Act — which will begin in 2026. The report observes that “some health policy experts project that recently enacted reforms could even apply upward pressure on launch prices,” as pharmaceutical manufacturers seek to recoup revenue that Medicare price negotiation may tamp down.

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Cigna’s New PBM Contract With Centene Brings Up-Front Capital Costs

Centene Corp. recently announced that it will shift the bulk of its pharmacy benefits business to Cigna Corp.’s Express Scripts PBM; while discussing Cigna’s latest quarterly results, the carrier’s executives told Wall Street analysts that the deal will likely be a drag on profitability in 2023. Health care insiders tell AIS Health, a division of MMIT, that regulatory compliance, temporarily elevated staffing needs, tech-related capital costs and manufacturer contracting transitions are the likeliest sources of overhead that the deal will generate.

Cigna executives told investors during a Nov. 3 conference call that the Centene deal, which analysts generally praised, would have some start-up costs. Centene Chief Financial Officer Drew Asher said during an Oct. 25 conference call with investors that “we have about $40 billion plus or minus of gross [drug] spend, and almost all of that is [currently] with Caremark,” CVS Health Corp.’s PBM. Cigna CEO David Cordani said that the deal will cover “approximately 20 million Centene members.”

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