Spotlight on Market Access

Current Market Access to PCSK9 Inhibitors

A federal appeals court on Feb. 11 rejected Amgen Inc.’s bid to resuscitate antibody patents for its PCSK9 inhibitor Repatha, a victory for Regeneron Pharmaceuticals, Inc. and Sanofi S.A., the manufacturers of Repatha’s only rival, Praluent. (Praluent was developed by both companies, but following a 2020 restructuring of their arrangement, Regeneron is now solely responsible for the drug in the U.S.). The judge in the case agreed with a lower court ruling 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.

MMIT Payer Portrait: Anthem, Inc.

Anthem, Inc. is the second-largest health insurer in the U.S., serving more than 33 million lives nationwide. It is also the largest Blue Cross and Blue Shield affiliate, acting as a Blues licensee in 14 states. Anthem's in-house PBM unit, IngenioRx, manages most of its pharmacy benefits, though CVS Specialty Pharmacy serves as its specialty PBM vendor. Anthem also operates Anthem Behavioral Health, and completed an acquisition of Beacon Health Options, one of the largest independent providers of behavioral health services in the U.S., in May 2020.

Pharma Manufacturers Face New Medicaid Landscape as States Carve Out Drug Benefit

California and other states that are carving out drug benefits and implementing one single formulary within their state Medicaid programs likely will pose both a challenge and an opportunity for drug manufacturers seeking Medicaid market share for their products, stakeholders say.

As of this year, five states have generally carved out their pharmacy benefits from their Medicaid managed care organization (MCO) contracts: Missouri, North Dakota, Tennessee, West Virginia and Wisconsin. That means the states themselves, rather than the Medicaid MCOs and their affiliated PBMs, now are managing their pharmacy benefits. New York’s and California’s carve-outs are scheduled to take effect this spring.

Medicine’s Evolution Has Brought Novel New Products, Opportunities for Pharma

Therapeutic interventions have evolved from people taking a pill every day to treat a condition to the one-time cell and gene therapies aimed at halting disease progression or even curing a disease. The rise of these innovative new products means that payers need more information than ever in order to properly assess treatments, as well as compare them with existing methods of care. They also can benefit from collaborations with manufacturers, including on innovative pricing models.

Orgovyx Offers New Oral Option for Prostate Cancer

People being treated for advanced prostate cancer now have a new oral option, offering patients the ability to not have to visit a provider for administration — an especially welcome alternative during the COVID-19 pandemic. Industry experts point to an array of reasons as to why the new drug should expect to get a lot of use. And a recent Zitter Insights survey indicates that the majority of oncologist respondents likely will prescribe it, with many saying they expect to favor it over the current standard of care.

As States Carve Out Medicaid Drug Benefits, Managed Care Orgs Push Back

Beginning in April, California and New York will join a growing list of states that have opted to carve out prescription drug benefits from their Medicaid contracts with insurers, wagering that the state can do a better job at negotiating drug prices with manufacturers than managed care organizations and their contracted PBMs.

States Take Varied Approaches to Rx Benefits in Medicaid

NOTES: Nevada plans to carve out the prescription drug benefit effective in FY 2023, when MCO contracts are renewed. California and New York plan to carve out pharmacy benefits starting in April 2021. Utah did n...

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.