Payer

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.

MMIT Reality Check on Acute Myeloid Leukemia (Apr 2019)

April 5, 2019

According to our recent payer coverage analysis for acute myeloid 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 myeloid 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 myeloid leukemia treatments shows that under the pharmacy benefit, almost 60% of the lives under commercial formularies are covered with utilization management restrictions.

Trends: With the FDA approving multiple novel new therapies over the past couple of years, more of the same is expected in 2019. In the oncology space, one expert says she is keeping an eye on quizartinib from Ambit Biosciences. Via AIS Health.

Radar On Market Access: Insurer Tools Aim to Help Members Save on Prescription Drugs

April 4, 2019

As many Americans continue to struggle to afford their medications, health insurers and their PBMs are responding with tools that help consumers not only understand the cost of drugs before prescriptions are filled, but also find ways to spend less money on them, AIS Health reported.

As many Americans continue to struggle to afford their medications, health insurers and their PBMs are responding with tools that help consumers not only understand the cost of drugs before prescriptions are filled, but also find ways to spend less money on them, AIS Health reported.

However payers choose to design such tools, two keys to their success include making improvements over time and making sure members know about them before they might need them, according to Nathan Foco, senior director of market and sales intelligence for Michigan-based Priority Health.

In late 2017, Priority Health began adding prescription drugs into its Cost Estimator tool to help members understand what they will pay for a prescription and how they could pay less by switching to a lower-priced alternative or opting for home delivery. Use of the prescription drug portion of the Cost Estimator has also increased since it was first rolled out, according to Foco.

“Like a lot of experiences like this, it takes a little while to get going,” he says. “You really can’t undercut the effort that you need to put into promoting and engaging members in the tool.”

Priority Health is not the only payer to offer tools that promote drug-cost transparency. Others include:

Cigna Corp., which in February said its network of health care providers will now have access to Surescripts’ Real-Time Prescription Benefit Tool, which gives them patient-specific medication coverage and cost information within their electronic health record or e-prescribing platform.

Blue Cross Blue Shield of Louisiana in February launched a tool called Rx Savings Solutions, which connects securely with members’ drug claim records and prepares a personalized prescription savings plan for them.

Aetna Inc. offers a tool that provides members with “real-time/moment-in-time drug pricing based on their benefit and status of their deductible,” according to a company spokesperson.

UnitedHealth Group’s OptumRx offers tools that allow enrollees to compare drug costs between generic and brand drugs, identify the lowest-cost option at an in-network retail pharmacy, or enroll in less-expensive home delivery of medications.

Radar On Market Access: New Postpartum Depression Drug Presents Payer Challenges

April 2, 2019

The FDA’s recent approval of the first medication specifically aimed at treating postpartum depression is drawing a favorable response from clinicians, while payers could face challenges.

The FDA’s recent approval of the first medication specifically aimed at treating postpartum depression is drawing a favorable response from clinicians, while payers could face challenges.

PBM executives tell AIS Health that the postpartum depression drug, Zulresso (brexanolone) injection, is likely to be covered under the medical, not the pharmacy, side of the benefit.

Zulresso’s initial U.S. list price “will be $7,450 per vial, resulting in a projected average course of therapy cost of $34,000 per patient before discounts,” says Alexis Smith, a spokesperson for Zulresso’s manufacturer, Sage Therapeutics, Inc.

As the medication must be administered as a 60-hour continuous intravenous infusion, it’s a challenge for a new mother to be hospitalized in an approved facility for two-and-a-half days for an IV infusion, says Dea Belazi, Pharm.D., president and CEO of AscellaHealth. Moreover, he says, there is “the fact that there are possible extensive side effects and the data on its [Zulresso’s] effectiveness [are] moderately better than placebo. The cost will also play a barrier,” he adds.

Camille Hoffman, M.D., associate professor in the University of Colorado’s Department of Ob/Gyn, describes the newly approved drug as “a breakthrough medication” that “rapidly improves postpartum depression out to, at least, 30 days following the one-time treatment.”

She acknowledges that the need to administer Zulresso via a 60-hour IV drip and its restricted distribution might present challenges. However, she says, “I hope that payers will consider these potential barriers in light of how quickly it acts to help women with severe postpartum depression.”

MMIT Reality Check on Opioid Dependence (Mar 2019)

March 29, 2019

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

According to our recent payer coverage analysis for opioid dependence 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 opioid dependence treatments shows that under the pharmacy benefit, more than 42% of the lives under commercial formularies are covered without utilization management restrictions.

Trends: To combat the opioid crisis, CMS in June 2018 guidance included an Information Bulletin providing states with considerations when designing approaches to covering critical treatment services for Medicaid-eligible infants with Neonatal Abstinence Syndrome, a post-natal opioid withdrawal syndrome that causes lengthy and costly hospital stays. Via AIS Health.

Trends That Matter for Cystic Fibrosis Medications

March 28, 2019

Payers typically use tools such as prior authorization and utilization review to manage cystic fibrosis treatments, but PBM experts say they are on the cusp of implementing more innovative strategies that might help to improve adherence while addressing the cost of cystic fibrosis drugs, AIS Health reported.

Payers typically use tools such as prior authorization and utilization review to manage cystic fibrosis treatments, but PBM experts say they are on the cusp of implementing more innovative strategies that might help to improve adherence while addressing the cost of cystic fibrosis drugs, AIS Health reported.

Cystic fibrosis, an inherited chronic disease that attacks the lungs and digestive organs, is caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. CFTR modulators and other therapies carry a high price tag, typically costing $250,000 to $368,000 per year. Other drugs, most of which do not have generic equivalents, can add tens of thousands of dollars to that total.

The majority of payers use traditional strategies, including pipeline monitoring, pharmacy and therapeutics committee drug review for formulary positioning, and prior authorization to confirm both the diagnosis and the presence of the specific genetic mutation targeted by the cystic fibrosis drugs, says Lynn Nishida, vice president of clinical product at Boston-based WithMe Health.

Still, “a growing number of payers are looking for out-of-the-box solutions for additional strategies in managing these drugs,” Nishida says. Cystic fibrosis drugs typically receive orphan drug status, which means payers cover them because they’re the only option for patients, but it can also mean they’re associated with higher costs, she says.

Managing infections in cystic fibrosis patients is a priority, says Mesfin Tegenu, R.Ph., president of PerformRx. However, effective antibiotics are also a main driver of cost.

Adherence to cystic fibrosis medications can be a challenge to manage, with studies showing a total reported mean adherence rate of 48% and a large drop-off in adherence in the adolescent years.