Industry Trends

Radar On Market Access: Copay Accumulators’ Use Rises; Virginia Passes Law Banning Such Programs

April 23, 2019

Payers are continuing to implement copay accumulators and copay maximizers in an effort to counter copay assistance from pharmaceutical manufacturers, according to a recent survey, AIS Health reported.

Payers are continuing to implement copay accumulators and copay maximizers in an effort to counter copay assistance from pharmaceutical manufacturers, according to a recent survey, AIS Health reported.

A Zitter Insights report shows that more than 90 million commercial lives are covered by payers that have a copay accumulator program — and it doesn’t look like these arrangements are going away any time soon.

It also explores the use of a similar kind of program: copay maximizers. Among 51 payer respondents covering 177.9 million lives, payers covering more than 50 million commercial lives have implemented a copay maximizer program. But payers representing 58% of covered lives say they do not have plans to incorporate maximizers within their benefits offerings.

Melinda Haren, a senior consultant at Zitter Insights, notes that accumulators and maximizers are focused on specialty drugs, particularly those products that are adjudicated through the pharmacy benefit.

The savings for payers — and the additional burden on manufacturers — are not insignificant. But drugmakers can do little to limit the use of these programs, at least in the short term, says Haren.

One recent effort may prove to be effective against accumulators: On March 21, Virginia Gov. Ralph Northam (D) signed a law that will go into effect Jan. 1, 2020, which states, in part, “When calculating an enrollee’s overall contribution to any out-of-pocket maximum, deductible, copayment, coinsurance, or other cost-sharing requirement under a health plan, a carrier shall include any amounts paid by the enrollee or paid on behalf of the enrollee by another person.”

This approach to counter accumulators “will likely be effective, at least in the near term,” maintains Jeremy Schafer, Pharm.D., senior vice president of payer access solutions at Precision for Value.

Perspectives on Insulin Management

April 18, 2019

Amid increasing public scrutiny of rising insulin prices, some health insurers are taking matters into their own hands to help their diabetic members afford the lifesaving medications, AIS Health reported.

Amid increasing public scrutiny of rising insulin prices, some health insurers are taking matters into their own hands to help their diabetic members afford the lifesaving medications, AIS Health reported.

At the integrated health system HealthPartners, the members who are hardest hit by rising insulin prices are those in high-deductible health plans, says Young Fried, vice president of pharmacy plan services. But she says insulin affordability is also an issue for Medicare members who are in the Part D “doughnut hole.”

One tactic that the organization’s health plan deploys to ease the burden on members is a policy called “plan pay the difference,” Fried says. If a brand drug becomes cheaper than the generic version after rebates, “we would actually have the member pay the generic copay instead of the brand, and then we would reimburse the pharmacy the brand cost, so that they’re made whole as well,” she says.

At Geisinger Health Plan, Medicare enrollees are the ones who have the most trouble paying for their insulin, according to Jamie Miller, the health plan’s system director of managed care pharmacy. Overall, Geisinger saw its spending in the diabetes drug class rise 13.8% between 2017 and 2018, she adds.

As Geisinger works out what it wants its Medicare benefit to look like in 2020, Miller says one goal is to make insulin more affordable for its senior members. Thus, the health plan is considering adding a sixth, “zero-dollar” tier to its Part D formulary where it would put insulin and select other drugs.

Radar On Market Access: CMS Finalizes Medicare Rates, Unveils ’20 Opioid Policies

April 18, 2019

CMS recently released its annual payment information and policy updates for Medicare Advantage, MA Prescription Drug (MA-PD) and stand-alone Prescription Drug Plans, underscoring the need for a better approach to opioid monitoring and management, AIS Health reported.

CMS recently released its annual payment information and policy updates for Medicare Advantage, MA Prescription Drug (MA-PD) and stand-alone Prescription Drug Plans, underscoring the need for a better approach to opioid monitoring and management, AIS Health reported.

Yet overall, industry experts say perhaps the most eye-catching features of CMS’s 2020 MA and Part D Rate Announcement and final Call Letter are the better-than-anticipated pay rate and the lack of worrisome new mandates, policy changes or major technical issues.

By incorporating an underlying “coding trend,” which CMS says will boost risk scores by 3.3%, on average, MA plans likely will see somewhere in the neighborhood of a 5.5% rate hike on average year over year, says Tim Courtney, director and senior consulting actuary of Wakely Consulting LLC.

“There just weren’t a lot of notable, earth-shaking changes this year [for the Part D program], which is good,” says Wayne Miller, R.Ph., vice president of pharmacy solutions for Gorman Health Group LLC.

“I think there’s more change coming in the [Medicare quality] star ratings measures being implemented around the opioids,” he adds, pointing to CMS’s addition of a 2020 display measure on how plans manage members’ use of opioids at higher dosages.

The agency in its 2020 final Call Letter urges Medicare plans to take voluntary steps to improve drug utilization review controls for opioids. It also says that it is “encouraging” Part D plan sponsors “to include at least one naloxone product on a generic or Select Care Tier.”

Radar On Market Access: PBM Trade Group Offers Alternative to Proposed Drug Rebate Changes

April 16, 2019

One day before executives from the country’s largest PBMs testified on Capitol Hill about rising drug prices, the Pharmaceutical Care Management Association (PCMA), which lobbies on behalf of PBMs, submitted a comment letter telling the Trump administration in no uncertain terms that a proposed rule aiming to upend the prescription drug rebate system will do more harm than good, AIS Health reported.

One day before executives from the country’s largest PBMs testified on Capitol Hill about rising drug prices, the Pharmaceutical Care Management Association (PCMA), which lobbies on behalf of PBMs, submitted a comment letter telling the Trump administration in no uncertain terms that a proposed rule aiming to upend the prescription drug rebate system will do more harm than good, AIS Health reported.

The proposed rule, released Jan. 31, would remove safe-harbor protections under the federal anti-kickback statute for rebates paid by drug manufacturers to PBMs, Part D plans and Medicaid managed care organizations, and it would create a new safe-harbor protection for point-of-sale drug discounts.

PCMA argues that the proposed regulation would significantly increase premiums for all Part D beneficiaries, raise taxpayer costs for the program and destabilize Medicare Part D.

The trade group also takes issue with the proposal’s attempt to set up a system in which “a yet-to-be-determined third-party administers chargebacks within some newly created infrastructure.” PCMA says such a process would be “long, costly, and complicated” and duplicate some of the work PBMs are already doing. Instead, it suggests that PBMs themselves should administer point-of-sale price concessions using the infrastructure that already exists.

According to Deb Devereaux, senior vice president of pharmacy at Gorman Health Group, the approach that PCMA is proposing makes sense.

“I don’t see a way that the PBM would not be involved,” she says.

Trends That Matter for Cancer Care

April 11, 2019

With more targeted and effective therapies launching to treat a variety of cancers, much of the focus has been not only on their efficacy but their costs, particularly to payers. A recent report from the physician perspective highlights their impact as far as cost on not only those stakeholders but also the patients they serve, AIS Health reported.

With more targeted and effective therapies launching to treat a variety of cancers, much of the focus has been not only on their efficacy but their costs, particularly to payers. A recent report from the physician perspective highlights their impact as far as cost on not only those stakeholders but also the patients they serve, AIS Health reported.

The Association of Community Cancer Centers released its 2018 Trending Now in Cancer Care Survey in February. Responding to the survey were 205 individuals from community cancer centers, academic centers, teaching hospitals and independent practices.

Leading the top threats to future growth were payer reimbursement requirements and “cost of drugs and/or new treatment modalities,” both at 48% among those categories ranked among the top five threats. Those were followed by “uncertainties in drug pricing reform policies,” at 40%.

When it came to patients, 49% of respondents said they had had a patient refuse treatment due to financial concerns over the past year, with 32% responding that they were not sure if that had occurred. In addition, 79% of respondents said they were “very” or “somewhat” concerned about patients refusing care due to financial worries.

Radar On Market Access: Drugmakers Are Trying Array of Tactics to Counter Copay Accumulator Programs

April 9, 2019

As more health plans are implementing copay accumulator programs, manufacturers are struggling to find ways to counter them, AIS Health reported.

As more health plans are implementing copay accumulator programs, manufacturers are struggling to find ways to counter them, AIS Health reported.

Drugmakers may want to “evaluate [their specialty pharmacy] network and consider narrowing it to independent SPs that will accept contracts precluding sharing with payers/PBMs the patients who are participating in your copay offset program,” recommends a recent survey report from Zitter Insights.

To make sure patients are getting the savings intended, manufacturers could allocate “fewer or no dollars to rebates and more dollars to coupons,” says Elan Rubinstein, Pharm.D., principal at EB Rubinstein Associates. “If the CMS safe harbor proposal is finalized as proposed, and if it becomes effective in January 2020 as proposed, this is in my view an approach that manufacturers will consider.”

However, according to Lisa Kennedy, Ph.D., chief economist at Epiphany, “it is hard to pull back rebates in a highly competitive area especially where there are limited formulary places versus where a manufacturer is in a segment where they have greater capacity for negotiation.”

Some drugmakers are offering patients debit cards to sidestep these programs, as it is more difficult to track these than, say, a coupon that a pharmacy must process, says Melinda Haren, a senior consultant at Zitter Insights. Companies also could offer rebate programs by which the patient pays out-of-pocket for a drug and then is reimbursed.

A few manufacturers are speaking with payers about contracting to exclude their drugs from these programs. But some legal risk exists with this approach because “money paid to patients doesn’t count toward the calculation for best price because it’s going to the patient, not the payer,” says Haren. In contrast, when manufacturers contract with payers, those details are “likely reportable under best price,” she says, acknowledging that this is a “gray area” for drugmakers.