Spotlight on Market Access

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. 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.

With COVID-19 continuing to ravage the United States and vaccinations still in the early stages of rolling out, the pandemic seems likely to remain the dominant headline in 2021. But other potential occurrences could have big impacts. AIS Health spoke with a variety of industry experts about what they’re keeping their eyes on in 2021.

As the Supreme Court decides on the fate of the Affordable Care Act (ACA), much of the focus understandably has been on the millions of people who would lose health insurance coverage and protections for pre-existing conditions if the law is overturned. Another not-so-often-discussed ramification of such a ruling is that the biosimilars market could be completely upended. While industry experts tell AIS Health that such an outcome probably will not occur, they still recommend that stakeholders prepare for this possibility.

Per-member per-year (PMPY) specialty drug spending rose 13.6% from 2018 to 2019, according to Pharmaceutical Strategies Group’s annual report, which analyzed 45 million pharmacy claims and 54 million medical claims. Contributing to the growth was a 10.3% increase in utilization and a 3.3% rise in costs per claim. Specialty drug spending under the pharmacy benefit saw the largest increase, driven by 19.6% higher utilization of such therapies. In terms of overall cost, inflammatory disorders ranked No. 1 among all drug categories, followed by oncology and multiple sclerosis.

Pharmaceutical treatment for different types of epilepsy generally still relies on tried-and-true generics, despite recent efforts by drug manufacturers to introduce new branded medications into the mix, PBM insiders say.

In 2020, the PBM industry continued to deepen its integration with other industry players, a trend that experts say is likely to continue in coming years. The PBM space has consolidated to the point that five firms — UnitedHealth Group’s OptumRx, CVS Health Corp.’s Caremark, Cigna Corp.’s Express Scripts, Anthem Inc.’s IngenioRx, Humana Inc.’s Humana Pharmacy Solutions, and the Blue Cross and Blue Shield affiliate-owned Prime Therapeutics LLC — manage the lion’s share of the pharmacy benefits offered to U.S. health plan members.

AIS Health’s data team on Dec. 15 updated the Directory of Health Plans subscriber dashboard and in-app spreadsheets with new enrollment data. This data primarily reflects third-quarter 2020 status but includes fourth-quarter 2020 data for Medicare Advantage products and some Medicaid data, based on availability at the state level.

The FDA in 2018 approved Epidiolex (cannabidiol) oral solution — the first FDA-approved drug that contains a purified drug substance derived from marijuana — for the treatment of seizures associated with two rare and severe forms of epilepsy in patients 2 years or older. Over the past two years, more treatments for epilepsy entered the market. Most recently, the FDA in August 2020 gave another indication to Epidiolex to treat seizures associated with tuberous sclerosis complex in people at least 1 year old. For most epilepsy medications on the market, the majority of insured people have plans that put them under the preferred/preferred (prior authorization and/or step therapy) tiers and covered/covered (PA/ST) tiers, as of December 2020.

Centene Corp. is the fourth-largest health insurer in the U.S., serving more than 20 million lives nationwide. About 70% of Centene's members are enrolled in public-sector health insurance products. Nationally, the company is No. 1 in managed Medicaid, holding contracts with 26 states (see map below). The insurer also dominates the Affordable Care Act exchanges, leading the national market with 2.2 million members in 20 states. In Sept. 2020, Centene unveiled plans to expand its exchange products to two new states, Michigan and New Mexico, plus 400 new counties in its existing markets for the 2021 plan year.

As we look back over the past year, the COVID-19 pandemic has been top of mind for many involved in pharma commercialization and coverage. Less than a year after scientists sequenced the COVID genome, the FDA granted emergency use authorization to vaccines from Pfizer Inc./BioNTech SE and Moderna, Inc. in December — an unprecedented time frame for vaccine development, testing and rollout. Shortly thereafter, vaccinations started to be administered. But that wasn’t the only pharma industry story of 2020. AIS Health spoke with a variety of industry experts on various trends over the past year.