Spotlight on Market Access

Payers expect an increase in their utilization of biosimilars compared with reference products, according to MMIT’s new Biosimilars Special Report. It found that of nine indications, payers are most likely to anticipate an increase in biosimilars for rheumatoid arthritis and breast cancer.

Health Care Service Corporation (HCSC) is the parent company of five large, member owned Blues insurers: Blue Cross and Blue Shield of Illinois, Montana, New Mexico, Oklahoma and Texas. The five subsidiaries enroll more than 16 million lives nationwide across the spectrum of health insurance products, though much of their membership is concentrated in Illinois and Texas. Originally founded in 1936 in Chicago as a prepaid insurance plan for hospital care, HCSC now enrolls more than half of all insured lives in Illinois.

Oncology service utilization has jumped in 2021 relative to 2020, but it’s still significantly depressed from its 2019 pre-pandemic levels. That means life sciences companies need to shift tactics — looking at screening and diagnosis regionally and at socioeconomic factors that contribute to incidence — in order to partner with providers and help patients, experts say.

More than 15 months after the U.S. declared that a public health emergency exists due to COVID-19, the health care sector is showing signs of rebounding. That’s according to the IQVIA Institute for Human Data Science report titled The Use of Medicines in the U.S.: Spending and Usage Trends and Outlook to 2025. But it’s certainly a mixed bag of news, and various services still could use some more improvement, observed industry experts at a recent webinar.

Medicare spent $2.6 billion more on 184 most common generic drugs compared with Costco member prices for the same prescriptions in 2018, according to a recent research letter published in JAMA Internal Medicine. By analyzing more than 1.4 billion Part D claims, researchers estimated that Medicare spent 13.2% more in 2017 and 20.6% more in 2018 than Costco members paid for 30-day and 90-day prescription fills. In 2018, Medicare spending exceeded the Costco member price on 43.2% of all 30-day and 90-day fills of the generic drugs studied.

Aduhelm (aducanumab), the Biogen Inc. Alzheimer’s drug recently approved by the FDA, seems less and less likely to be dispensed to patients, as prominent providers, practitioner groups and experts have all publicly argued against doing so. Several health insurers have said they will not pay for the drug unless patients pass strict prior authorization standards — and the FDA approval itself could be in jeopardy as the agency’s acting commissioner has called for the HHS Office of Inspector General (OIG) to investigate the process that led to the approval.

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.