Spotlight on Market Access

PBMs Face More Regulatory Challenges Amid Transition

In the year ahead, Trump administration drug pricing policies are likely to be changed or revoked by the Biden administration and court challenges, although which policies will be affected — and to what extent — is still unclear, policy experts tell AIS Health.

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© 2024 MMIT

Centene Enters Agreement to Buy Behavioral Health Stalwart Magellan Health

Centene Corp. on Jan. 5 said it agreed to acquire Magellan Health, one of the largest independently held providers of behavioral health services in the U.S. Magellan is currently contracted to serve 19 payer clients (see the top three below), which enroll about 16.5 million medical lives overall, according to the latest update to AIS’s Directory of Health Plans. Centene owns the fifth-largest behavioral health organization (BHO) in the national payer landscape, Cenpatico, and is also affiliated with Managed Health Network, a BHO inherited from Centene’s 2016 acquisition of Health Net. Centene is also set to acquire Magellan’s wholly owned PBM, Magellan Rx Management. Magellan currently serves 5.5 million pharmacy lives, while Centene’s PBM subsidiary Envolve Pharmacy Solutions has 6.1 million lives as of MMIT’s third-quarter 2020 lives data update.

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Orgovyx Offers Oral Option for People With 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. 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.

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Pharma Innovation Is Poised to Continue Beyond COVID Vaccines, Drugs This Year

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.

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Biosimilars May Be at Risk Depending On Supreme Court’s Affordable Care Act Ruling

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.

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Specialty Drug Spending Continues to Rise, Driven by Higher Utilization

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.

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With Rare Exceptions, Plans Stick With Generic Drugs for Epilepsy Treatment

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.

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2020 in Review: PBMs Continue Integration, Face More Regulatory Challenges

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.

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Third-Quarter DHP Update Puts COVID’s Impact Into Focus

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.

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Current Market Access to Epilepsy Medications

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.

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