Radar on Drug Benefits

Remote Physiologic Monitoring Use Among Medicaid Enrollees Skyrocketed From 2019 to 2021

Between 2019 and 2021, the use of remote physiologic monitoring (RPM) via wearable devices and mobile applications soared by more than 1,300% among Medicaid enrollees, which was driven by a small number of providers, according to a recent Health Affair study.

Based on Transformed Medicaid Statistical Information System Analytic Files data from Jan. 1, 2019, to Dec. 31, 2021, the study found that the number of RPM recipients per 100,000 Medicaid enrollees increased from 2.1 recipients in 2019 to 29.6 recipients in 2021 and started to accelerate with the March 2020 onset of the COVID-19 public health emergency. Among over 5,600 distinct providers who billed RPM claims for Medicaid enrollees in 2021, more than half of the claims were from 5% of providers.

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2023 Drug Trends Included GLP-1s, Humira Biosimilars, $0 Cost Share

Notable pharmacy benefit trends in 2023 claims data included increased use of GLP-1s for weight loss, shifting market dynamics amid high demand for AbbVie Inc.'s Humira (adalimumab) and its biosimilar competitors and increasing approval of expensive gene therapies. All this took place amid “persistent price inflation” across most drug categories, according to a new report by PBM analytics firm Xevant.

According to Xevant’s 2023 Drug Trend Report, which analyzed pharmacy claims data from its commercial plan clients, 2023 plan-paid amounts across all brand and generic non-specialty and specialty drugs went up an average of 20% from 2022. In addition, the number of specialty prescriptions processed by plans increased by 11% in 2023. GLP-1 utilization increased by 400%, while claims for Humira and its biosimilars increased by 25%.

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Part D Plans Get Ready for Potentially ‘Messy’ Rollout of M3P Program

This article originally appeared as part of the May 16 issue of Radar on Medicare Advantage.

For the first time ever, Medicare Part D beneficiaries in 2025 will have the opportunity to spread their prescription drug expenses over the course of the plan year. While Part D sponsors must offer the option to enrollees effective Jan. 1, 2025, plans face multiple considerations and tasks prior to then. One of their most immediate concerns, industry experts say, is factoring in potential administrative costs and/or financial losses associated with the new Medicare Prescription Payment Plan (M3P, as many are calling it) into bids due next month.

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News Briefs: Optum Rx Unveils New Pricing Model Starting in 2025

Optum Rx announced on May 20 a new program, Clear Trend Guarantee, that will combine guarantees into a single per member cost metric. The PBM will make Clear Trend Guarantee available to plan sponsors starting on Jan. 1, 2025. In a press release, Optum Rx described Clear Trend Guarantee as “an alternative, guarantee-based pricing model that combines retail, home delivery, specialty drug and rebate components into one per member guarantee” and said the program would “ultimately deliver value to individuals and families who want predictability in their premiums and drug costs.” Meanwhile, Patrick Conway, Optum Rx’s CEO, wrote in a May 22 LinkedIn post that Clear Trend Guarantee “means plan sponsors will have another option to manage their pharmacy spend with greater predictability and choice to help manage lowest net cost.” Optum Rx last year announced other alternative pricing models, including a pass-through model using average ingredient costs.

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Specialty Drug Benefits Survey Spotlights Gene Therapy, Biosimilar Strategies

While over 90% of health plans receive specialty medication rebates under the pharmacy benefit, the receipt of medical-benefit rebates has risen in the past one to two years, according to the 2024 Trends in Specialty Drug Benefits Report, published by Pharmaceutical Strategies Group, an EPIC company. The report also covered topics like the management strategies of Humira biosimilars and the financial risk associated with cell and gene therapy.

The report is based on responses from 185 benefits leaders from employers, unions/Taft-Hartley plans and health plans representing plan sponsors of approximately 86.6 million covered lives, conducted from Sept. 18, 2023, through Oct. 13, 2023.

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PBMs’ 1Q Earnings Calls Are All About Biosimilar, GLP-1 Programs

During their first-quarter earnings calls, the companies that own the three largest PBMs shared a wealth of details about how the market is responding to their new programs targeting GLP-1 and biosimilar drugs. Wall Street analysts noted that those remarks offered a welcome highlight amid decidedly mixed results in the firms’ health insurance divisions.

The Cigna Group CEO David Cordani opened his prepared remarks during the company’s May 2 earnings call by spotlighting the company’s “focus on biosimilars to drive greater affordability,” calling it one of Cigna’s key strategic growth drivers.

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High Price Tag, Accelerated Approval for New NASH Drug May Give Payers Pause

When the FDA approved Rezdiffra (resmetirom) in March, it gave patients with a serious form of liver disease a long-awaited treatment option tailored to their specific condition. But the drug’s accelerated approval and high price tag are already spurring at least one health insurer to consider options like restrictive coverage criteria and value-based contracting.

NASH represents a progression from a more common condition, nonalcoholic fatty liver disease (NAFLD). It occurs when patients start developing liver inflammation that can eventually lead to liver scarring, dysfunction, and even liver failure and cancer.

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Pharmacists Play Key Role in Addressing Health Inequities, Execs Say at Conference

PBMs and health plans are increasingly relying on pharmacists to manage their members’ medication costs and improve adherence, particularly among marginalized groups who have often been overlooked, according to speakers at the third annual Pharmacoequity Conference, held May 3 at the University of Pittsburgh. The panelists also said pharmacists adopting a so-called “cost-plus” model can help bring more transparency to drug pricing, make medications more affordable, and help people become healthier and save payers money.

The term “pharmacoequity” was popularized in 2021 by Utibe Essien, M.D., an internal medicine physician and former professor at the University of Pittsburgh who is now at the University of California, Los Angeles. Essien has defined pharmacoequity as “equity in access to pharmacotherapies or ensuring that all patients, regardless of race and ethnicity, socioeconomic status, or availability of resources, have access to the highest quality of pharmacotherapy required to manage their health conditions.”

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AMCP Panel Details Barriers to Broad Biosimilar Adoption

For biosimilar use to truly take flight, health plans need to focus on easing switches between original products and reference products — and policymakers should consider expanding interchangeability, according to expert presenters at the Academy of Managed Care Pharmacy (AMCP) annual conference in New Orleans.

There is a lot of "promise" and "optimism" around biosimilars, said Cate Lockhart, Pharm.D., Ph.D., executive director of the Biologics and Biosimilars Collective Intelligence Consortium, during an April 17 panel at the AMCP conference, but there is more that could be done to increase systemic savings and improve patient access.

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News Briefs: FDA Sets Date for Donanemab Panel

The FDA on June 10 will consult a panel of outside experts on donanemab, Eli Lilly & Co.’s Alzheimer’s drug. In the advisory committee hearing, third-party experts in neuroscience and drug development will hear presentations from the FDA and Lilly, then be able to question Lilly and FDA officials on the data behind donanemab’s application for approval. A decision on the drug had been expected earlier this year, but the FDA decided to delay it in order to let the advisory committee hearing take place. However, the advisory committee’s recommendation does not carry any official weight. That was a point of controversy after the FDA in 2021 granted accelerated approval to Biogen Inc. & Eisai’s Co.’s Aduhelm (aducanumab), ignoring near-unanimous disapproval from a similar panel. Several advisers resigned from the advisory panel after the Aduhelm accelerated approval decision.

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