Benefit Design

Industry Will Continue to See 340B, Patient-Paid Prescription Impact as IRA Looms

The pharmaceutical industry and the broader health care services market currently are experiencing a series of trends that are likely to persist into 2023, said Adam J. Fein, Ph.D., CEO of Drug Channels Institute, during a Dec. 16 webinar titled Drug Channels Outlook 2023. These include pressure on insurers’ traditional coverage of generics from patient-paid prescriptions, ongoing 340B litigation and providers’ increased presence within the specialty pharmacy market. But the impact of the biggest disruption, the Inflation Reduction Act (IRA), is yet to come. In this second of a two-part series, AIS Health highlights these trends projected by the longtime industry expert.


More Complex Specialty Drug Management, Pandemic Pressures and Inflation Reduction Act Were Some 2022 Trends

Both the specialty pharmacy market and the home infusion space continued to grow in 2022. Congress finally passed legislation that will allow Medicare to negotiate drug prices with manufacturers for the first time, and many of the impacted agents are expected to be specialty medications. As payers grappled with their drug costs, some implemented new utilization management strategies. And the COVID-19 pandemic, now approaching its fourth year, remained a disruptor in both the specialty pharmacy and home infusion markets. AIS Health, a division of MMIT, spoke with various industry experts on multiple 2022 issues impacting those industries.


FDA Approves Alzheimer’s Agent Leqembi Shortly After Release of Congressional Aduhelm Report

Less than two years after the FDA approved the first treatment for Alzheimer’s that was aimed at targeting the underlying disease process, it has approved a second similar agent. Payers are likely to cover the drug, one industry expert says, but they almost certainly will try to place restrictions on their coverage.

On Jan. 6, the FDA gave accelerated approval to Eisai Co., Ltd. and Biogen Inc.’s Leqembi (lecanemab-irmb) for the treatment of Alzheimer’s disease in people with mild cognitive impairment or mild dementia stage of disease. People must have confirmed presence of amyloid beta pathology before starting treatment. The agency gave the humanized immunoglobulin gamma 1 monoclonal antibody fast track, priority review and breakthrough therapy designations.


Ruling on Transgender Care May Have Major Impact on Third-Party Administrators

A district court judge in Washington state ruled on Dec. 19 that Blue Cross and Blue Shield of Illinois violated the anti-discrimination provision of the Affordable Care Act when it served as a third-party administrator (TPA) of health benefits and refused to cover medically necessary gender-affirming care for a transgender boy.

The decision “is something that could have a big impact on administrators” of health benefits, David Kaufman, an attorney with Laurus Law Group LLC, tells AIS Health, a division of MMIT. It came one month after the court certified the case as a class-action lawsuit, meaning other individuals who had their gender-affirming care denied could potentially be involved, “so the case probably has a long way to go before it’s settled law,” according to Kaufman.


Expect Industry Impact From Vertical Integration, Provider M&A Activity, Humira Biosimilars

Multiple trends within the pharmaceutical industry and the broader health care services market currently are underway and likely to persist into 2023, said Adam J. Fein, Ph.D., CEO of Drug Channels Institute, during a Dec. 16 webinar titled Drug Channels Outlook 2023. Others, such as the launch of the first biosimilar versions of Humira (adalimumab) are set to take place in the upcoming year. In this first of a two-part series, AIS Health highlights the first half of the trends projected by the longtime industry expert.


In 2024 ACA Payment Rule, Admin Offers Two Fixes for ‘Choice Overload’

While Americans are shopping for 2023 Affordable Care Act marketplace plans, CMS is already looking ahead to the next plan year, as the agency on Dec. 12 issued its annual omnibus proposed rule governing marketplace plans for 2024.

Experts say the policy shifts likely to draw the most industry attention are the newly proposed limits on non-standardized exchange plans, which build on regulations that have already drawn the ire of health insurers. However, CMS seems to give a nod to potential pushback by offering up an alternative means of limiting the dizzying array of plan options consumers now face.


Customer Satisfaction With PBMs Drops to a Three-Year Low, Study Reports

Plan sponsors’ overall satisfaction with their PBMs was 7.8 on a 1-10 scale in 2022, down from 8.2 last year, according to Pharmaceutical Strategies Group’s 2022 Pharmacy Benefit Manager Customer Satisfaction Report. The report was based on surveys completed by 236 individuals representing employers, unions/Taft Hartley plans, health plans and health systems that covered an estimated 76 million lives. Respondents reported a lower likelihood to recommend their PBM to a colleague or to renew their contract without issuing a competitive request for proposal this year, highlighting costs as the primary driver to leave the PBM.

Among core PBM services, satisfaction was highest for “offering competitive traditional drug discounts” and “meeting financial guarantees.” As clinical and cost management programs play a key role in reducing overall costs, 82% of respondents reported using utilization management, while only 8% used gene therapy financial protection programs.


Prime Studies Reveal Efficacy, Costs of Specialty Agents

Two recently published studies by Prime Therapeutics LLC shine a light on specialty drug costs. In the first, researchers found that a newer agent for cystic fibrosis is effective, but it is so costly that its related savings in health care services avoided do not offset its cost. The second study showed that a focused communication effort for a transition to a preferred infliximab biosimilar, among other strategies, has resulted in millions of dollars in savings in only the first three months after implementation of the strategy.

Posters on the studies were presented at the Academy of Managed Care Pharmacy (AMCP) Nexus meeting.


Memory Fitness Offerings Jump 38% as MA Insurers Promote Mind-Body Wellness

Nearly three years ago, when insurers were in the early days of experimenting with new offerings under CMS’s reinterpretation of “primarily health related” supplemental benefits, very few plans were offering benefits specifically geared toward “memory fitness.” Now, a new Faegre Drinker analysis shows that these benefit offerings will be featured in more than 1,300 plan benefit packages (PBPs) next year — an increase of 38% over 2022.


Horizon BCBS Launches NovaWell to ‘Reimagine’ Behavioral Health

A new behavioral health venture that sprung from an innovative Horizon Blue Cross Blue Shield of New Jersey initiative is focused on embedding its integrated approach within other health plans and provider groups. NovaWell, a Horizon affiliate that launched Nov. 14, is offering a suite of technology-forward solutions aimed at tackling the country’s ongoing mental health crisis. Jolted into the public consciousness by the COVID-19 pandemic, the crisis is characterized by rising rates of anxiety and depression amid a shortage of trained professionals.

Backed by more than five years of testing and program design aimed at addressing the behavioral health needs of Horizon’s members, the NovaWell suite brings an integrated care management approach supported by network-enhancing solutions to a wider audience. Two of the company’s four core offerings, a fully integrated clinical model called NovaClinical and a network solution known as NovaNetwork, are positioned to bolster health plans, Suzanne Kunis, president and CEO of NovaWell, tells AIS Health, a division of MMIT.