Benefit Design

Drug shortages have grabbed headlines in recent months, with patients struggling to fill prescription medications that treat conditions including asthma and attention-deficit/hyperactivity disorder (ADHD), and providers struggling to stock and administer specialty drugs, especially in oncology. Experts tell AIS Health, a division of MMIT, that PBMs don’t have an abundance of options to ameliorate the shortages and may be unlikely to try the limited workarounds that they do have.

New research prepared for the American Society of Health-System Pharmacists (ASHP) by researchers from the University of Utah found that 301 drug shortages were in effect by the end of the first quarter of the year — a five-year high.

Issues around so-called alternate funding companies that carve out specialty drugs have existed for several years now, but only recently has a manufacturer taken legal action against such a company. On May 5, AbbVie Inc. filed a lawsuit (1:23-cv-02836) against Payer Matrix, LLC in the U.S. District Court for the Northern District of Illinois Eastern Division over its “fraudulent and deceptive scheme to enrich itself by exploiting AbbVie’s PAP [patient assistance program] through the enrollment of insured patients into a charitable program not intended for them.”

AbbVie states that it is “bring[ing] this action to stop Payer Matrix’s harmful conduct and protect its program so it can continue to serve its intended purpose — providing free drugs to uninsured and underinsured patients who otherwise could not afford their AbbVie medicine.”

On May 5, AbbVie Inc. filed a lawsuit (1:23-cv-02836) against Payer Matrix, LLC in the U.S. District Court for the Northern District of Illinois Eastern Division over its “fraudulent and deceptive scheme to enrich itself by exploiting AbbVie’s PAP [patient assistance program] through the enrollment of insured patients into a charitable program not intended for them.”

Payer Matrix was not able to provide a comment on the lawsuit by press time. But prior to the filing and shortly before AbbVie updated its PAP language earlier this year, AIS Health, a division of MMIT, conducted an interview with Michael Jordan, Payer Matrix’s chief business officer (CBO), to learn more about the company’s practices.

The FDA recently expanded the use of BeiGene, Ltd.’s Brukinsa (zanubrutinib) to include its use in the treatment of a hematologic cancer. The agent is already approved for three other rare types of non-Hodgkin lymphoma. Respondents to a Zitter Insights survey said that while its availability will result in a lower level of unmet need in the treatment of chronic lymphocytic leukemia (CLL), there is still moderate or high unmet need for the condition.

On Jan. 1, the FDA expanded the label of Brukinsa to include the treatment of adults with CLL or small lymphocytic lymphoma (SLL). CLL and SLL are the same disease, a type of non-Hodgkin lymphoma, except CLL cancer cells are mostly in the blood and bone marrow, while in SLL, the cells are mainly in the lymph nodes. CLL is the most common adult leukemia.

Specialty drug management continues to be of utmost importance to plan sponsors, which are implementing a variety of levers to try to keep spending in check while making sure their beneficiaries are receiving appropriate care. Pharmaceutical Strategies Group (PSG), an EPIC company, recently released its 2023 Trends in Specialty Drug Benefits Report, which examines the use of these strategies and overall trends in managing these costly medications.

The report, released May 3, is the 10th annual report; it previously was published under the Pharmacy Benefit Management Institute (PBMI) brand. Conducted from Sept. 20, 2022, through Oct. 21, 2022, the survey included 182 benefits leaders from employers, unions/Taft-Hartley plans and health plans representing plan sponsors of approximately 86.7 million covered lives. Genentech USA, Inc., a member of the Roche Group, co-sponsored the report with PSG.

In the first year of the COVID-19 pandemic, when many people were having trouble accessing basic personal protective equipment, Highmark Blue Cross Blue Shield began sending out care kits including PPE and other items to support seniors at home. The response from Medicare Advantage members was so positive that what started out as a feel-good gesture has become a full-blown supplemental benefit, and the insurer continues to refine the kits to meet members’ evolving needs and ensure continued satisfaction with the plan.

Starting with plan year 2022, eligible Highmark members were given the option to receive one of 17 condition care kits. Commonly referred to as the “big blue box,” each kit is filled with a variety of items tailored to a specific condition, with a focus on member choice and high quality, speakers from Highmark and its strategic partner RR Donnelley explained during the 14th Annual Medicare Market Innovations Forum, held on March 28 and 29 in Orlando. RR Donnelley, a firm that provides marketing and business communications, commercial printing, and related services, has assisted CVS Health Corp.'s Aetna and Humana Inc. with similar initiatives.

Although new treatments hold tremendous promise for addressing obesity and the myriad health issues associated with it, Medicare Part D is barred from covering them, and private insurers’ coverage is variable. And there are multiple barriers that will make fixing those coverage gaps challenging, health policy experts said during a recent panel discussion.

Perhaps the most headline-grabbing obesity treatment is semaglutide, which Novo Nordisk sells under the brands Ozempic (for Type II diabetes) and Wegovy (for weight loss). That drug has recently been the topic of a cascade of news articles discussing the drug’s ability to help patients shed stubborn pounds, side effects such as hair loss, and shortages faced by some diabetes patients due to semaglutide’s skyrocketing popularity.

In response to industry pushback against a proposal that would have significantly limited how many non-standardized Affordable Care Act exchange plans issuers can offer, CMS in a newly finalized regulation opted for a less-restrictive approach — at least for 2024. Yet policy and actuarial experts aren’t convinced that the newly set limits are enough to solve the “choice overload” problem that’s made it increasingly hard for consumers to find ideal coverage.

With its troubled years — and mass insurance carrier exits — largely behind it, the ACA exchange market has become increasingly competitive. On the one hand, that’s good for consumers and the market at large, as research has shown competition tends to push down premiums. But the Biden administration and consumer advocates have also grown increasingly concerned that the proliferation of plan options available to insurance shoppers is making it nearly impossible to differentiate between products and choose what’s right for them. While the average ACA marketplace consumer had 25.9 plans to choose from in 2019, that number rose to 107.7 by plan year 2022, according to HHS. Research, including a 2016 RAND Corp. review of 100 studies, indicates that having too many choices can lead consumers to make poor health insurance enrollment decisions.

Biomarker testing is an important tool in cancer care, but a recent survey found payer coverage issues are creating access barriers. According to CancerCare, researchers found that biomarkers helped providers offer personalized care for various cancers for nearly all — 93% — respondents. Twenty percent of surveyed patients were able to forgo unneeded chemotherapy and/or radiation, while 10% found that they were eligible for a clinical trial.

However, the survey also found that 29% of people who had biomarker testing had insurance that did not cover it, prompting them to undergo appeals, obtain financial assistance or pay out of pocket for the service. In addition, 25% of patients said that their insurer required prior authorization (PA) for the process, a tactic that can delay access to treatment.

Prime Therapeutics LLC and Magellan Rx Management, a Prime company as of the end of last year, recently presented findings from a series of studies that used integrated medical and pharmacy claims to assess real-world drug use. Their findings show that different strategies can help identify potential member issues that could impact payer costs.

The studies were presented at the Academy of Managed Care Pharmacy (AMCP) Annual Meeting, held in San Antonio, Texas, March 21 to 24.