Market access

MMIT Reality Check on Ovarian Cancer (4Q2023)

A review of market access for ovarian cancer treatments shows that under the pharmacy benefit, about 42% of the lives under commercial formularies are covered with utilization management restrictions. Around 19% of the lives under Medicare formularies are not covered for at least one of the drugs.

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News Briefs: Rite Aid Is Poised to Auction Off ‘Elixir’ PBM

Rite Aid Corp. has delayed the auction of its PBM, Elixir Rx Solutions, as part of its Chapter 11 bankruptcy filing. According to a court filing, the auction was moved from Nov. 20 to Dec. 21 following a Nov. 21 hearing held by the District of New Jersey U.S. Bankruptcy Court. Rite Aid filed for bankruptcy on Oct. 15, at which time MedImpact Healthcare Systems presented a $575 million “stalking horse” offer for the company’s PBM — meaning an initial bid on a bankrupt company's assets from an interested buyer that aims to avoid low bids in a court auction. Under the newly revised schedule, competitive bids for Elixir must be received by Dec. 18 ahead of the Dec. 21 auction — which is the same date as the auction being held for Rite Aid’s retail stores.

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MMIT Reality Check on Follicular Lymphoma (4Q2023)

A review of market access for follicular lymphoma treatments shows that under the pharmacy benefit, about 42% of the lives under commercial formularies are covered with utilization management restrictions. Around 44% of the lives under Medicare formularies are not covered for at least one of the drugs.

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MMIT Reality Check on Colorectal Cancer (4Q2023)

A review of market access for colorectal cancer treatments shows that under the pharmacy benefit, about 51% of the lives under commercial formularies are covered with utilization management restrictions. Around 41% of the lives under Medicare formularies are not covered for at least one of the drugs.

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MMIT Reality Check on Cystic Fibrosis (4Q2023)

A review of market access for cystic fibrosis treatments shows that under the pharmacy benefit, about 63% of the lives under commercial formularies are covered with utilization management restrictions. Around 21% of the lives under Medicare formularies are not covered for at least one of the drugs.

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News Briefs: CDC Makes More RSV Immunizations Available to Infants

The CDC announced on Nov. 16 that it had made available more than 77,000 additional doses of Beyfortus (nirsevimab-alip), a monoclonal antibody intended to protect infants from severe respiratory syncytial virus (RSV) disease. Since the FDA approved Beyfortus in July, there have been supply issues and insurance coverage limitations for RSV medications. Sanofi, which manufactures Beyfortus alongside AstraZeneca, noted last month that it had seen “an unprecedented” level of demand for the medication and that it was working with the CDC to distribute more doses through the agency’s Vaccines for Children program.

CMS has delayed its plan to cover Medicare patients’ full cost of preexposure prophylaxis (PrEP) using FDA-approved antiretroviral drugs to prevent HIV infection in high-risk patients, according to KFF. CMS had announced the proposal in July and expected to make it official on Oct. 10, but KFF said the delay has occurred while CMS “is still working out details on how to transition coverage for patients already taking the drugs.” The drugs can cost more than $20,000 per year in the U.S.

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Papers Delve Into Payment Options for Gene Therapies

Most employer-sponsored plans that have stop-loss insurance coverage should be able to pay for expensive gene therapies that have proven to be cost-effective, according to a recent paper from Health Affairs Scholar. However, a separate Health Affairs analysis published this month argues that payers must assess alternative payment models to afford the medications, which can cost more than $1 million per dose.

Aaron S. Kesselheim, M.D., one of the authors of the latter Health Affairs paper says that plans have taken varied approaches to paying for gene therapies ranging from “extremely permissive to extremely tight coverage.”

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Zepbound Faces Market Access, Supply Challenges

Zepbound (tirzepatide), Eli Lilly and Co.’s latest glucagon-like peptide 1 (GLP-1) agonist product and Lilly's first entrant in that category to be marketed only as a weight loss drug, garnered FDA approval on Nov. 8. The approval intensified already fierce public interest in using GLP-1s for weight loss — which could be bad news for payers, especially commercial plan sponsors, who were already concerned before Zepbound’s approval that the high cost and broad appeal of the drugs will cause premiums to spike.

A recent WTW survey found that 38% of employer-backed health plans cover weight loss drugs, while 22% are considering adding coverage. Mercer found that 42% of large employers cover GLP-1 drugs for weight loss. Brokers and employer plan sponsor trade groups have identified burgeoning GLP-1 utilization as a possible reason for future premium hikes.

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ICER Report Calls for Greater Coverage Policy Transparency

Major payer coverage policies across select categories often met fair access criteria for cost sharing, clinical eligibility, step therapy and provider restrictions, according to the third annual “Barriers to Fair Access” assessment published by the Institute for Clinical and Economic Review (ICER).

The analysis examined coverage policies for 18 drugs across 10 commercial formularies, eight Affordable Care Act exchange plans and the Veterans Health Administration national formulary, representing 42 million enrollees in total. ICER asked the payers for coverage policy information and leveraged the MMIT Analytics Market Access Database for additional information. (MMIT is the parent company of AIS Health, which maintains journalistic independence and did not play a role in producing the report.)

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ICER Sets Sights on Expanding ‘Fair Access’ Formulary Analysis

In its annual assessment of whether prescription drug formularies overly restrict access to select medications, the Institute for Clinical and Economic Review (ICER) gave insurers high marks. While it acknowledges that coverage policy information needs to be much more transparent, this year’s report concludes that “major payer coverage policies for 18 drugs often met fair access criteria for cost sharing, clinical eligibility, step therapy, and provider restrictions.”

However, ICER President-Elect Sarah Emond says the nonprofit research institute is fully aware that its analysis can only do so much to examine all the myriad, complicated facets of what truly defines “fair access.” Therefore, she adds, ICER is actively working on how to make future reports more comprehensive.

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