Spotlight on Market Access

State governments have begun to pursue aggressive policies to make PBMs more transparent, accountable to plan sponsors and less expensive to contract with — efforts that are bolstered by Rutledge v. Pharmaceutical Care Management Association (PCMA), a lawsuit decided by the Supreme Court at the end of 2020 in which the justices held that states were not in violation of the Employee Retirement Income Security Act of 1974 (ERISA) in attempting to regulate the rates at which PBMs reimburse pharmacies.

Cigna Corp. — which made headlines earlier this year when it indicated patients could receive a monetary award if they switch from a high-priced psoriasis drug to a cheaper biologic — now appears to be making that strategy an official program, starting with a different drug.

In a recent press release, the insurer revealed that starting in July, two approved biosimilars for Janssen’s immunosuppressive drug Remicade (infliximab) — Avsola and Inflectra — will move to preferred status on its formularies. “With these updates, Cigna is taking concrete steps to help patients and plans realize the promise of alternative, clinically effective treatment options,” the company said.

While biosimilars Avsola and Inflectra are picking up ground, Remicade is still more advantaged, holding covered or better status for 61% of all insured lives.

The FDA recently expanded the indication of a drug for certain types of urothelial cancer, the most common form of bladder cancer. Payers and oncologists appear to be divided, however, on the drug’s place in a treatment regimen.

PBMs have used formulary exclusions as an effective way to negotiate with manufacturers for several years. However, at least one payer has gotten more aggressive with its tactics to get members to move from an excluded drug to one with preferred status, dangling a financial incentive for members. That effort is facing pushback from several medical associations, but if it proves to be successful, other companies could follow suit, suggest industry experts.

Recently, health insurers have begun focusing on social determinants of health (SDOH) and the role these factors play on health outcomes. Then the COVID-19 pandemic put even more of a spotlight on the issue, disproportionately affecting people of color and low-income communities. Recognizing the impact that SDOH can have, AllianceRx Walgreens Prime is partnering with Highmark Inc. to launch a pilot outreach program focused on the impact of SDOH on people with multiple sclerosis (MS).

From 2009 to 2019, commercial per-member per-month (PMPM) costs have almost doubled, from $17.28 to $32.73, an increase of 89%, according to the latest Medical Pharmacy Trend Report from Magellan Rx Management. The report also found that the cost of Remicade (infliximab), the top commercial drug, grew two-and-a-half times during that same period.

Spurred by CMS’s decision to cover chimeric antigen receptor T-cell therapies under Medicare, commercial payers are beginning to systematize approvals for CAR-T treatment as use of these breakthrough cancer therapies is beginning to ramp up, experts say.

“Despite the costs of CAR-T, I know many plans were already looking at providing coverage prior to the CMS decision,” which was released in October 2019, says Dan Danielson, R.Ph., senior director of the access experience team at PRECISIONvalue. “CMS’s decision provided confirmation that they were on the right track,” he tells AIS Health, a division of MMIT.

In a move that signals Blue Cross Blue Shield plans are getting increasingly serious about driving down the cost of prescription drugs, five major Blues affiliates on June 22 launched a startup company that aims to “offer innovative medication solutions to patients, providers and customers.”

Blue Cross Blue Shield of Massachusetts, Blue Cross Blue Shield of Michigan, Blue Shield of California, Highmark Inc. and Independence Blue Cross are all providing “significant funding” to support the launch of Evio, which they characterize as an “independent pharmacy solutions startup.”

As an extension of Formulary Navigator, MMIT has launched Medical Drug Lists as the first-ever solution for health plans to manage medical benefit coverage in an automated workflow. Together with Navigator, MMIT’s payer solutions now cover the ever-increasing need of managing drug coverage across benefits.