Benefit Management

AMCP Panel Details Barriers to Broad Biosimilar Adoption

For biosimilar use to truly take flight, health plans need to focus on easing switches between original products and reference products — and policymakers should consider expanding interchangeability, according to expert presenters at the Academy of Managed Care Pharmacy (AMCP) annual conference in New Orleans.

There is a lot of "promise" and "optimism" around biosimilars, said Cate Lockhart, Pharm.D., Ph.D., executive director of the Biologics and Biosimilars Collective Intelligence Consortium, during an April 17 panel at the AMCP conference, but there is more that could be done to increase systemic savings and improve patient access.

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Insurers Urged to ‘Look Carefully’ at AI Tools in Wake of New Rule

On April 26, the Biden administration released a final rule which, in addition to strengthening the Affordable Care Act’s antidiscrimination protections, attempts to address rising concern about health insurers’ use of artificial intelligence, algorithms and other tools to make care and coverage decisions.

Managed care experts say that the new regulation — titled Nondiscrimination in Health Programs and Activities — likely won’t catch insurers off guard given the scrutiny they are already receiving about their use of AI. However, “they’re going to have to look carefully at their use of any kind of automated tools,” predicts Harvey Rochman, a litigation partner at Manatt, Phelps & Phillips, LLP. “There’ll be a large focus on the kinds of automated tools that plans can use in various aspects of their work, from claims to utilization management.”

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Rumored Regs Could Help Payers, PBMs Streamline Digital Therapeutic Coverage

Notable changes to the way breakthrough medical devices are covered by Medicare and other payers could be coming soon, with CMS poised to make some therapeutics eligible for Medicare coverage, and some stakeholders pushing for new legislation to expand digital therapeutic coverage. In the meantime, commercial health plans and PBMs are grappling with how best to cover prescription digital therapeutics (PDTs).

Health plans and PBMs have varying approaches to digital therapeutic reimbursement. Some plans may place one digital therapeutic in the medical benefit, while others may cover PDTs as part of a pharmacy benefit. That’s because PDTs occupy a unique space in the health benefits landscape: They aren’t pharmaceuticals, but they share many characteristics of a maintenance medication in practice.

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Expiring Policies Threaten Progress on Opioid Use Disorder Med Uptake

States and the federal government have taken steps in recent years to increase access to medications to treat opioid use disorder (OUD), such as allowing prescribing via telehealth and easing other restrictions for providers. However, some of those policies are set to expire in the coming months and more needs to be done to ensure patients receive the much-needed treatments, health policy experts tell AIS Health, a division of MMIT.

A KFF analysis found a 24% increase from 2019 to 2022 in the dispensing of buprenorphine, one of three FDA-approved medications for OUD. A separate KFF report published last month showed that 63% of Medicaid enrollees with an OUD diagnosis received medication treatment in 2020.

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Rumored Regs Could Help Payers, PBMs Streamline Digital Therapeutic Coverage

Notable changes to the way breakthrough medical devices are covered by Medicare and other payers could be coming soon, with CMS poised to make some therapeutics eligible for Medicare coverage, and some stakeholders pushing for new legislation to expand digital therapeutic coverage. In the meantime, commercial health plans and PBMs are grappling with how best to cover prescription digital therapeutics (PDTs).

Health plans and PBMs have varying approaches to digital therapeutic reimbursement. Some plans may place one digital therapeutic in the medical benefit, while others may cover PDTs as part of a pharmacy benefit. That’s because PDTs occupy a unique space in the health benefits landscape: They aren’t pharmaceuticals, but they share many characteristics of a maintenance medication in practice.

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‘LTSS-Like’ Supplemental Benefits Aim to Fill a Gap, but Enrollment Remains Low

Millions of seniors report needing long-term services and supports that can assist with daily activities and disease management, but many don’t qualify for Medicaid, the primary source of LTSS coverage. Medicare Advantage plans have stepped up to fill in the gap with “LTSS-like” supplemental benefits, which range from select Special Supplemental Benefits for the Chronically Ill such as home modifications and service dog support, to Expanded Primarily Health-Related Benefits, including adult day services, in-home support services and caregiver support.

New research from ATI Advisory explores who has access to and ultimately enrolls in MA plans that offer LTSS-like supplemental benefits. The analysis of CMS data found that 82% of Medicare-only beneficiaries (i.e. those who are not dually eligible for Medicaid) have access to at least one plan that offers at least one LTSS-like benefit. Despite the wide availability of LTSS-like plans — particularly in high-population urban areas — just 9% of beneficiaries are enrolled in them, representing about 2 million people.

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Current Market Access to GLP-1s

In March, the FDA approved Novo Nordisk’s Wegovy (semaglutide) for cardiovascular risk reduction, which could further boost the already-strong sales for the GLP-1 weight-loss medication.

Specifically, Wegovy is now approved to reduce risk of “major adverse cardiovascular events (MACE) including cardiovascular death, non-fatal heart attack (myocardial infarction) or non-fatal stroke” in adults who are either overweight or obese and have established cardiovascular disease, per a Novo press release.

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Wegovy’s New Indication Turns Up Heat on Employers Sweating GLP-1 Costs

When the FDA approved Novo Nordisk’s Wegovy (semaglutide) for reducing the risk of serious heart problems, it paved the way for Medicare Part D plans to cover the drug. Industry experts also predict that the drug’s expanded indication will pressure more commercial insurers and their plan-sponsor clients to cover the pricey — and increasingly popular — medication.

“The pressure is just going to be too much” for commercial plans to avoid broadening their GLP-1 coverage, says Debra Devereaux, principal and chief pharmacy/clinical officer at Rebellis Group. However, she cautions that there may not be many significant coverage-policy changes this year.

Many commercial health plans already cover the drug for weight loss. Data from MMIT, AIS Health’s parent company, show that in 31 states, pharmacy formularies that cover more than half of commercial-plan enrollees categorize Wegovy as “preferred” or “preferred with utilization management restrictions.”

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Big Three PBMs Cover Opill With $0 Cost Sharing for Most Commercial Plans

The Big Three PBMs — UnitedHealth Group’s Optum Rx, CVS Health Corp.’s Caremark, and The Cigna Group’s Express Scripts — have opted to cover Perrigo Co.’s over-the-counter birth control pill, Opill (norgestrel), at no cost to members in most non-grandfathered commercial plans, according to one expert. That suggests they are taking proactive steps to comply with potential rulemaking that could require most health plans to cover Opill and other types of over-the-counter birth control without cost sharing.

“There has been pretty broad, in the industry, adoption of Opill to the ACA preventive list,” Cody Midlam, Pharm.D., tells AIS Health, a division of MMIT. Midlam is a director at the benefits consulting firm WTW. “If a drug is on that list, that is generally available at $0 cost share at the point of sale for members.”

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New Mexico Law Reduces Drug Spending for Mental Health, SUD Patients

A 2022 New Mexico law eliminating in-network mental health and substance use disorder (SUD) treatment copayments, coinsurances and deductibles in plans regulated by the state led to a significant decline in out-of-pocket spending for prescriptions treating those conditions, according to a recent JAMA Health Forum study. However, early results showed that the number of prescriptions dispensed did not change in the six months after New Mexico’s No Behavioral Cost-Sharing (NCS) rule went into effect.

Samantha J. Harris, Ph.D., one of the study’s authors, tells AIS Health that the NCS is “really groundbreaking” in that it’s the first state law to eliminate cost-sharing for mental health and SUD treatments. She adds that “as people are looking at the next frontier of mental health or health care financing, this is an exciting policy option,” although she notes that “it remains to be seen whether it’s going to impact utilization of services [and] whether this is going to improve overall health and well-being.”

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