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MMIT Reality Check on Major Depressive Disorder (Mar 2020)

March 20, 2020

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

According to our recent payer coverage analysis for major depressive disorder 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 major depressive disorder treatments shows that under the pharmacy benefit, about 36% of the lives under commercial formularies are covered with utilization management restrictions.

Trends: Nasal spray Spravato (esketamine) entered the market in spring 2019 as the first truly new product for major depressive disorder in years, but despite its potential to be a game-changer for those with treatmentresistant depression, most people with the condition will continue to be treated with tried-and-true generics.

Perspectives on Legality of Closed Medicaid Formularies

March 19, 2020

As part of long-awaited guidance that CMS issued to states on Jan. 30 outlining how they can test-drive a fixed federal Medicaid budget and more program flexibilities, the Trump administration invited states to try out something else that hasn’t been done before: implement a closed drug formulary for a portion of their Medicaid population, AIS Health reported.

As part of long-awaited guidance that CMS issued to states on Jan. 30 outlining how they can test-drive a fixed federal Medicaid budget and more program flexibilities, the Trump administration invited states to try out something else that hasn’t been done before: implement a closed drug formulary for a portion of their Medicaid population, AIS Health reported.

“For the first time, participating states will have more negotiating power to manage drug costs by adopting a formulary similar to those provided in the commercial market, with special protections for individuals with HIV and behavioral health conditions,” CMS said in its press release unveiling the Healthy Adult Opportunity demonstration, which states can apply for via a Section 1115 Medicaid waiver.

Currently, states’ Medicaid programs must cover all FDA-approved drugs, as mandated by federal law. But CMS is suggesting that states can waive that requirement for the population they choose to cover under their demonstration — likely people who are covered by Medicaid expansion — and still participate in the Medicaid Drug Rebate Program.

But some industry experts tell AIS Health they’re not sure whether that will be legally permissible.

“I have my doubts as to whether this will bear legal scrutiny because it goes against the entire Medicaid Drug Rebate Program, which is rebates in exchange for open formularies,” says Jeff Myers, the former CEO of Medicaid Health Plans of America and founder of health care consulting firm OptDis.

Indeed, “the legal side is obviously the giant question with the whole Healthy Adult Opportunity program,” Jason Karcher, an actuary with Milliman, Inc., tells AIS Health. “We just don’t know how the courts will ultimately see this, although I think it would be fair to be skeptical that we’ll actually get to see a waiver under this [guidance] make it in the near future.”

Radar On Market Access: COVID-19 Outbreak Could Impact Drug Supply Long-Term

March 19, 2020

Industry experts say the COVID-19 outbreak is unlikely to limit U.S. drug supplies in the short or middle term. However, they tell AIS Health that increased demand for longer-duration stocks of medication from self-isolating patients could strain supplies going forward.

Industry experts say the COVID-19 outbreak is unlikely to limit U.S. drug supplies in the short or middle term. However, they tell AIS Health that increased demand for longer-duration stocks of medication from self-isolating patients could strain supplies going forward.

“We are told at this point that we’re not seeing any [drug] shortages in the marketplace today,” says Kelly McGrail-Pokuta, Prime Therapeutics’ vice president of pharmaceutical trade.

On Feb. 27, FDA Commissioner Stephen Hahn released a statement that said disruptions to the pharmaceutical supply chain have been minimal so far. The statement also said that the FDA was especially focused on 20 manufacturers that are particularly dependent on operations in China, and found that “none of these firms have reported any shortage to date.”

But on March 10, the FDA postponed all inspections of overseas drug manufacturing facilities “through April, effective immediately,” according to another statement released by Hahn.

During a pandemic, the CDC recommends anyone taking prescription medication to manage a chronic condition keep an expanded supply of their medicine on hand. As more people self-isolate, and consumers seek to spend less time in stores and other public places, demand for backup medication is likely to increase.

Mike Schneider, a principal at Avalere Health who previously worked for CVS Caremark, says PBMs and payers will have to rethink their typical posture toward chronic medication as enrollees stock up in anticipation of self-isolation.

“Hopefully, with everything going on related to coronavirus and people wanting to stock up, those quantity limits would be eased or eliminated for the most part for chronic meds,” says Schneider.

The Blue Cross Blue Shield Association’s “network of 36 independent and locally operated” affiliates have all decided to waive prescription refill limits on maintenance medications, according to America’s Health Insurance Plans. Other non-Blues insurers have also taken steps to allow members to refill prescriptions in advance.

Experts say it’s difficult to know whether the drug supply will be affected down the road. Schneider says consumer stockpiling and the FDA’s move to suspend foreign inspections could both make an impact on future supply.

Radar On Market Access: Insurers, Pharma Spar Over Copay Accumulator Provision

March 17, 2020

Health insurers are praising a provision in a recently proposed regulation that gives commercial plans greater leeway to run so-called copay accumulator programs, which prevent drug manufacturer coupons from counting toward patients’ annual deductibles or out-of-pocket cost limits. But the pharmaceutical industry slammed the proposal as “misguided” and liable to prevent patients from getting vital medications.

Health insurers are praising a provision in a recently proposed regulation that gives commercial plans greater leeway to run so-called copay accumulator programs, which prevent drug manufacturer coupons from counting toward patients’ annual deductibles or out-of-pocket cost limits. But the pharmaceutical industry slammed the proposal as “misguided” and liable to prevent patients from getting vital medications.

“I do think these programs are here to stay, and I do think they will continue to grow in terms of the absolute numbers as we head into ’22 and beyond,” Jayson Slotnik, a partner at Health Policy Strategies, LLC., tells AIS Health. From insurers’ point of view, copay accumulator programs help combat the perverse incentives that drug manufacturer coupons create: steering patients to pricey brand-name drugs by obscuring their true cost.

In its 2021 proposed Notice of Benefit and Payment Parameters, CMS clarifies that all non-grandfathered individual and group market health plans “have the flexibility to determine whether to include or exclude coupon amounts from the annual limitation on cost sharing, regardless of whether a generic equivalent is available.”

To America’s Health Insurance Plans, it’s important to allow the use of copay accumulator programs even for drugs that don’t have a generic version in order to spur competition between branded drugs that can treat the same condition. “Drug manufacturers recognize this and spend billions of dollars to dilute the impact of competition by providing coupons for brand drugs that do not have a generic equivalent,” the trade group wrote in its comment letter about the proposed rule.

But the Pharmaceutical Research and Manufacturers of America (PhRMA) sees it very differently.

“It would compromise patients’ ability to adhere to prescribed medicines at a moment when insurance coverage for medicines continues to erode; it would put patient health and financial security in danger; it would run directly counter to the Administration’s stated policy of lowering patient out-of-pocket costs for prescription drugs; and it could undermine the appeal and availability of high-deductible health plans,” PhRMA wrote.

MMIT Reality Check on Hereditary Angioedema (Mar 2020)

March 13, 2020

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

According to our recent payer coverage analysis for hereditary angioedema 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 hereditary angioedema treatments shows that under the pharmacy benefit, about 67% of the lives under commercial formularies are covered with utilization management restrictions.

Trends: The FDA will review BioCryst Pharmaceuticals, Inc.’s application for oral, once daily berotralstat for the prevention of swelling attacks in patients with hereditary angioedema, with a decision expected by early December 2020.

Radar On Market Access: Insurers Deploy Array of Strategies to Manage Asthma

March 12, 2020

While payers have long used telephone-based care management teams to improve outcomes for members with asthma, now they’re also deploying other strategies to fine-tune their outreach to those who are in most need of support, AIS Health reported.

While payers have long used telephone-based care management teams to improve outcomes for members with asthma, now they’re also deploying other strategies to fine-tune their outreach to those who are in most need of support, AIS Health reported.

Every member with asthma should have an asthma action plan, says Karen Meyerson, director of commercial care management at Michigan-based Priority Health. Such a plan, which is completed by a patient’s doctor, should include a medication list, tips on recognizing worsening symptoms and steps for responding in an emergency.

Priority Health members can also use a cost-estimator tool to shop for the lowest-cost drugs. For example, members can use the tool to discover a less-expensive generic drug and a pharmacy where their asthma medications cost less.

Nurses and social workers at EmblemHealth conduct home visits to assess the level of dust and mold in asthma patients’ environments, Richard Dal Col, M.D., the insurer’s chief medical officer, tells AIS Health.

To help promote medication adherence, EmblemHealth charges members who use combination inhalers one copay, instead of two. The insurer also allows a 90-day supply for rescue and maintenance medications; depending on their plan design, members may be able to pay one copay, rather than three.

Blue Shield of California members with asthma can receive a home visit by a nurse or a physician. Phillip Baldi, D.O., lead medical care director at the insurer, says while home visits seem expensive, the insurer’s rates with a company providing home visits is comparable to what it pays for an in-person visit to a doctor’s office. “If we can divert five emergency room visits, we can have 50 home visits,” he tells AIS Health.

The insurer is also evaluating offering select maintenance drugs at lower or no copays for members with asthma.