Spotlight on Market Access

Publicly Traded Insurers Tout Pharmacy Divisions

Although the fourth quarter of 2020 brought financial challenges for some health insurers due to surging coronavirus infections, the pharmacy-focused divisions of those publicly traded firms seemed to provide a universal bright spot.

FDA Approval Makes Breyanzi Third CAR-T Therapy in NHL

With the FDA’s approval of Bristol Myers Squibb’s Breyanzi (lisocabtagene maraleucel) earlier this month, there are now three chimeric antigen receptor T cell (CAR-T) therapies to treat a certain type of non-Hodgkin’s lymphoma (NHL). A Zitter Insights poll shows that payers do not anticipate its approval as having much of an impact on their management of the space.

Shields’ Purchase of Excelera Highlights Integrated Specialty Pharmacy Industry

As more health systems are creating their own specialty pharmacies, two major players in the space are coming together. In mid-January, Shields Health Solutions unveiled a deal to purchase ExceleraRx Corp. for an undisclosed amount. The new company could provide these entities with more leverage when it comes to payer networks and manufacturer distribution.

Administration Delays Implementation of Rebate Rule; Congress Is Likely to Repeal It

The Biden administration will suspend implementation until 2023 of the so-called “rebate rule,” a Trump administration regulation that would have revamped the Medicare prescription drug rebate system. D.C. insiders expect Congress to eliminate the rule before then for budgetary reasons, but say that drug pricing and PBM regulation will be high on the health care agenda after policymakers address the latest issues arising from the COVID-19 pandemic.

Hike in Drug List Prices Has Downstream Effect on Patient, Payer Costs

Even though drug manufacturer discounts and rebates have been rising, when wholesale list prices for prescription drugs more than doubled over a period of seven years, that still triggered large increases in patient out-of-pocket costs and insurer payments, according to a recent study published in JAMA Network Open. The researchers analyzed pharmacy claims for five patent-protected specialty drugs and nine brand-name drugs associated with the highest total expenditures by commercial insurers in 2014 and found that their average wholesale price (AWP) increased by 129% from 2010 to 2016. Median insurer expenditures on the 14 drugs analyzed grew 64%, while median patient out-of-pocket costs went up 53% during that time.

CMS Greenlights Tennessee’s Closed Medicaid Formulary Demonstration

When CMS on Jan. 8 approved Tennessee’s Section 1115 Medicaid waiver — making it the first state to try an “aggregate cap” approach to Medicaid financing — the agency also took the unprecedented step of authorizing Tennessee to set up a “commercial-style” closed drug formulary while still receiving statutory Medicaid drug rebates for covered drugs.

Vaccine Race, Regulatory Risk, Robust M&A Will Impact Drugmakers in 2021

In the year ahead, the three main “developments to watch” in the branded pharmaceuticals sector will include COVID-19 vaccine scale-up and distribution, continued legislative and regulatory pushback against high drug prices, and robust levels of merger and acquisition activity, according to a new report from Moody’s Investors Service.

Tracking Coverage Uptake With MMIT’s Dynamic Tools

In the product launch phase, pharmaceutical manufacturers are under pressure to commercialize quickly and deliver early revenue growth. Establishing early, competitive access to payers and PBMs is crucial to meeting this challenge, and MMIT Landscape uniquely addresses these needs.

Tennessee’s Medicaid Drug Lives by Formulary

The state of Tennessee controls 1.2 million Medicaid drug lives in four formularies as of January 2021. Tennessee is unique among states in that the vast majority of its Medicaid beneficiaries are enrolled in managed care plans. UnitedHealth Group’s OptumRx serves as the state’s pharmacy benefits manager for the entire Medicaid program.

State Medicaid Enrollment Growth Since January 2020

Medicaid enrollment in Tennessee has grown 6.7% since January 2020, largely due to the impact of the COVID-19 pandemic. Virtually all of Tennessee’s Medicaid population is served by one of three contracted insurers: Anthem, Inc.’s Amerigroup unit, BlueCross BlueShield of Tennessee and UnitedHealthcare.