Market Access

Radar On Market Access: Plans Must Cover PrEP at No Cost After USPSTF Recommendation

July 11, 2019

A few recent actions, as well as one expected next year, are expected to help bring down rates of HIV infection. And while the efforts should make it easier for certain populations to gain access to preexposure prophylaxis (PrEP) that helps prevent them from acquiring HIV, some issues are likely to stand in the way of eliminating all infections, AIS Health reported.

A few recent actions, as well as one expected next year, are expected to help bring down rates of HIV infection. And while the efforts should make it easier for certain populations to gain access to preexposure prophylaxis (PrEP) that helps prevent them from acquiring HIV, some issues are likely to stand in the way of eliminating all infections, AIS Health reported.

The FDA initially approved Gilead Sciences, Inc.’s Truvada (emtricitabine 200 mg/tenofovir disoproxil fumarate 300 mg) in 2004 to treat HIV infection. But in 2012, the agency approved it to reduce the risk of HIV infection in adults, the only therapy indicted for this use.
In its final recommendation, published June 11, the U.S. Preventive Services Task Force (USPSTF) recommended that “clinicians offer preexposure prophylaxis (PrEP) with effective antiretroviral therapy to persons who are at high risk of HIV acquisition,” giving the recommendation an “A” rating. This grade, the highest one possible, means that the USPSTF recommends the service, as “there is high certainty that the net benefit is substantial.”

The grade also means that, per the Affordable Care Act, “a group health plan and a health insurance issuer offering group or individual health insurance coverage” must provide coverage for free of items or services that the USPSTF gives an “A” or “B” ranking.

Payers will still be able to impose “reasonable medical management techniques,” such as prior authorization, notes Elan Rubinstein, Pharm.D., principal, EB Rubinstein Associates.

“Making PrEP available without cost-sharing eliminates a major barrier to this landmark HIV prevention tool,” said Michael Ruppal, executive director of The AIDS Institute. “At a time when out-of-pocket costs are rising for patients as they seek access to medications, this recommendation is a win both for patients and public health.”

Radar On Market Access: Expensive Drugs Launched After OCM Baseline Period Are Hamstringing Providers, Study Shows

July 9, 2019

CMS’s Oncology Care Model (OCM) is about halfway through its five-year pilot. Developed by the CMS Center for Medicare & Medicaid Innovation, the voluntary pilot is aimed at providing better quality and more coordinated cancer care for Medicare fee-for-service beneficiaries, as well as other payers, while at a lower cost.

CMS’s Oncology Care Model (OCM) is about halfway through its five-year pilot. Developed by the CMS Center for Medicare & Medicaid Innovation, the voluntary pilot is aimed at providing better quality and more coordinated cancer care for Medicare fee-for-service beneficiaries, as well as other payers, while at a lower cost.

One criticism of the model is that providers’ costs are compared with targeted costs that are based partly on their spending from 2012 to 2015, the OCM baseline period. When the actual costs come in below the targeted costs, that earns providers a performance-based payment. But with so many costly oncology therapies launching after the baseline period, this is making it hard for providers to gain a performance-based payment, AIS Health reported.

That was the focus of a poster presentation by Tennessee Oncology at last month’s American Society of Clinical Oncology meeting. Researchers maintained that “when avoidable inpatient, post-acute, and emergency department (ED) costs are minimized, a practice’s actual costs should be lower than target costs, allowing practices the opportunity for shared and performance-based savings. However, we hypothesized that the ability for an oncology practice to successfully meet target costs may be hampered by the skyrocketing prices of novel therapy drugs implemented into clinical practice after baseline period cost calculations.”

They examined Tennessee Oncology patients with non-small cell lung cancer and bladder cancer treated during the second performance period (January through June 2017). The researchers concluded that the use of expensive novel therapies in concordance with NCCN guidelines in indications approved after the OCM baseline period “poses significant challenges to practices. Future value-based care initiatives in oncology need more accurate ways to account for rising drug costs and expanding treatment indications to prevent penalties for following guideline appropriate care.”

MMIT Reality Check on Psoriatic Arthritis (Jul 2019)

July 5, 2019

According to our recent payer coverage analysis for psoriatic arthritis treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

According to our recent payer coverage analysis for psoriatic arthritis treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

To help make sense of this new research, MMIT’s team of experts analyzes the data and summarizes the key findings for you. The following are brief highlights. To read the full piece, including payer coverage, drug competition and prescriber trends, click here.

Payer Coverage: A review of market access for psoriatic arthritis treatments shows that under the pharmacy benefit, about 74% of the lives under commercial formularies are covered with utilization management restrictions.

Trends: Manufacturers with franchises across indications often hold contracting power and improved positio, which is everything in this market. In terms of contracting, Humira is the product to beat, and Enbrel battles for the second place.

Radar On Market Access: States Plow Ahead on ‘Subscription’ Models for Hep C Therapy

July 3, 2019

Last month, CMS approved Medicaid state plan amendments for Louisiana and Washington state, thus allowing the states to launch innovative value-based purchasing arrangements. Both states’ programs are aimed at working with partnering drug manufacturers to better handle the high costs for curative hepatitis C treatments, and may be the harbinger of similar initiatives by additional states.

Last month, CMS approved Medicaid state plan amendments for Louisiana and Washington state, thus allowing the states to launch innovative value-based purchasing arrangements. Both states’ programs are aimed at working with partnering drug manufacturers to better handle the high costs for curative hepatitis C treatments, and may be the harbinger of similar initiatives by additional states.

Louisiana “put the bow” on its plan to get hepatitis C treatment to Medicaid enrollees and incarcerated individuals over the next five years via a “Netflix”-like subscription model, a state official tells AIS Health.

On June 26, CMS approved Louisiana’s Medicaid state plan amendment authorizing the state to negotiate supplemental rebate agreements from prescription drug manufacturers, using a “modified subscription” model that initially focuses on antiviral agents for hepatitis C.

Meanwhile, Washington state was scrambling to finalize its agreement with AbbVie in time to launch its hepatitis C subscription-model program for Medicaid by July 1. On June 12, CMS gave the green light to Washington state’s Medicaid state plan amendment proposal to negotiate supplemental rebate agreements involving value-based purchasing arrangements with drug manufacturers.

“It’s clear from the recent developments in Washington [state] and Louisiana that payers are looking for innovative ways to pay for the increasing number of promising but costly medications coming to market, including the curative Hep C therapies,” Academy of Managed Care Pharmacy Chief Operating Officer Cynthia Reilly said in a statement to AIS Health.

“The subscription model is one of several models being implemented in real-world settings,” Reilly said. “It’s hard to say if it will become the dominant model. It’s more likely that we will continue to see experimentation and refinements, including with subscription-based, value-based and outcomes-based models.”

MMIT Reality Check on Acute Lymphoblastic Leukemia (Jun 2019)

June 28, 2019

According to our recent payer coverage analysis for acute lymphoblastic leukemia treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

According to our recent payer coverage analysis for acute lymphoblastic leukemia treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

To help make sense of this new research, MMIT’s team of experts analyzes the data and summarizes the key findings for you. The following are brief highlights. To read the full piece, including payer coverage, drug competition and prescriber trends, click here.

Payer Coverage: A review of market access for acute lymphoblastic leukemia treatments shows that under the pharmacy benefit, about 42% of the lives under commercial formularies are covered with utilization management restrictions.

Trends: Kymriah is the first FDA-approved CAR-T cell therapy indicated for patients up to 25 years of age with relapsed or refractory B-cell ALL. Most payers list Kymriah as a drug that needs prior authorization, because a number of restrictions exist when using this medication.

Radar On Market Access: Troy Medicare Aims to Launch Pharmacist-Centered Model in NC

June 25, 2019

Troy Medicare, a small Medicare Advantage plan start-up, aims to shake up the North Carolina MA marketplace during the coming fall open enrollment by offering a pharmacist-centered delivery model that will pay local, independent pharmacists directly for enhanced care management services to seniors.

Troy Medicare, a small Medicare Advantage plan start-up, aims to shake up the North Carolina MA marketplace during the coming fall open enrollment by offering a pharmacist-centered delivery model that will pay local, independent pharmacists directly for enhanced care management services to seniors.

“We will go live on Jan. 1, 2020,” in a five-county, “semi-rural” service area around Charlotte, N.C., Troy CEO Flaviu Simihaian tells AIS Health.

Under its model, Troy is working with Community Pharmacy Enhanced Services Network (CPESN). According to Simihaian, the new MA Prescription Drug (MA-PD) plan will contract with CPESN to provide reimbursement of $30 to $50 per member per month (PMPM), relying on participating pharmacists to document their services to determine reimbursement amounts.

Brian Anderson, a principal with Milliman, Inc., tells AIS Health that reimbursement is a key issue.

“It is an innovative model,” he says. “It’s been in the conversation for about 15 years, but the challenge has always been the reimbursement aspect and verifying the [pharmacist] consultations are occurring, and the pharmacist is actually spending time with the patient.”

“It hasn’t worked through the current NCPDP [National Council for Prescription Drug Plans] transaction processes” for Part D plans, Anderson says. “But if they’re just paying an administrative fee PMPM back to those pharmacists, that would be different than having the administrative fee paid through the claims payment system.”

Then there is the question of whether the benefit of pharmacist consultation is offsetting the potentially deeper prescription-drug discounts and higher rebates that large pharmacy chains or mail order pharmacy are able to give, as compared to small independent pharmacies, he says.