Market access

MMIT Reality Check on Schizophrenia (September 2022)

A review of market access for schizophrenia treatments shows that under the pharmacy benefit, about 26% of the lives under commercial formularies are covered with utilization management restrictions. Around 17% of the lives under Medicare formularies are not covered for at least one of the drugs.

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Study: Pharma Companies Often Profit From Donations to Patient Assistance Charities

Pharmaceutical companies often profit from their donations to non-profit patient assistance charities that are intended to help people afford high-cost medications, according to a study published in this month’s edition of the journal Health Affairs.

HHS’s Office of Inspector General (OIG) has provided guidance on the charities and cracked down in recent years on several charities and drug manufacturers. However, the authors noted that “the current regulations or enforcement permit donations that violate the spirit of Medicare’s Anti-Kickback Statute,” which prohibits pharma companies from covering Medicare Advantage enrollees’ out-of-pocket drug spending for the drugs they manufacture.

MMIT Reality Check on Acute Migraine (September 2022)

A review of market access for acute migraine treatments shows that under the pharmacy benefit, about 47% of the lives under commercial formularies are covered with utilization management restrictions. Around 49% of the lives under health exchange formularies are not covered for at least one of the drugs.

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TennCare Acquiesces to CMS’s Demands for Demo Revisions

Bowing to CMS’s request after another public comment period, Tennessee is reluctantly pursuing a series of changes to the pending TennCare III demonstration that had been approved by the Trump administration for a start date of Jan. 8, 2021. In what one source says is an unusual back-and-forth on public display, the state will abandon its notorious plans to implement a closed Medicaid formulary and adopt a fixed funding mechanism.

Shortly before President Joe Biden took office, the Trump administration in January 2021 approved Tennessee’s request to use an “aggregate cap” for Medicaid funding that many industry observers had likened to a block grant. Through that approach, Tennessee would have received federal Medicaid funds based on a fixed budget target that is determined by CMS and the state using historical enrollment and costs data. If spending fell below that target cap but certain quality goals were met, the state would earn up to 55% of annual savings to reinvest back into other state health programs.

MMIT Reality Check on Breast Cancer HR+/HER2- (September 2022)

A review of market access for treatments of adults with hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2-) shows that under the pharmacy benefit, about 44% of the lives under commercial formularies are covered with utilization management restrictions. Around 33% of the lives under Medicare formularies are not covered for at least one of the drugs.

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MMIT Reality Check on Non-Small Cell Lung Cancer Systemic Therapy (August 2022)

A review of market access for non-small cell lung cancer systemic therapy treatments shows that under the pharmacy benefit, about 38% of the lives under commercial formularies are covered with utilization management restrictions. Around 38% of the lives under Medicare formularies are not covered for at least one of the drugs.

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MMIT Reality Check on Ulcerative Colitis (August 2022)

A review of market access for ulcerative colitis treatments shows that under the pharmacy benefit, about 64% of the lives under commercial formularies are covered with utilization management restrictions. Around 34% of the lives under Medicare formularies are not covered for at least one of the drugs.

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Insurers Brace for When U.S. Stops Buying COVID-19 Vaccines, Therapeutics

The federal government will stop purchasing COVID-19 vaccines and therapeutics as soon as this fall, Biden administration officials said recently — meaning payers will have to procure vaccines and treatments like any other commercial pharmaceutical product. Health care experts tell AIS Health, a division of MMIT, that the move is likely to make vaccines and therapeutics less accessible and introduce dispensing costs that could drive up premiums.

The Biden administration is transitioning away from the “acute emergency phase where the U.S. government is buying the vaccines, buying the treatments, buying the diagnostic tests. We need to get out of that business over the long run,” White House Coronavirus Response Coordinator Ashish Jha, M.D., said during an Aug. 16 event organized by the U.S. Chamber of Commerce.

Payers May Restrict Coverage of New Fast-Acting Oral Drug for Major Depression

The FDA on Aug. 19 approved the first and only rapid-acting oral drug for major depressive disorder (MDD), a treatment that is being hailed by its manufacturer as a “potential game-changer” for people struggling with the difficult-to-treat condition.

One pharma analyst expressed optimism about the drug’s ability to disrupt the MDD treatment market. However, experts from the PBM sector predict that payers may not embrace the drug warmly given how many generics are available to treat depression.

MMIT Reality Check on Duchenne Muscular Dystrophy (August 2022)

A review of market access for Duchenne muscular dystrophy treatments shows that under the pharmacy benefit, about 39% of the lives under commercial formularies are covered with utilization management restrictions. Around 28% of the lives under health exchange formularies are not covered for at least one of the drugs.

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