Payer

Radar On Market Access: New Migraine Drugs Could Spark Value-Based Contracting

November 29, 2018

Therapy for chronic migraine — a condition that’s been notoriously difficult to treat and which often leads to significant direct and indirect health care costs — has been upended with the recent approval of three injectable monoclonal antibody products in a new preventive medication class that’s significantly more effective than older preventive migraine drugs, a researcher says.

Therapy for chronic migraine — a condition that’s been notoriously difficult to treat and which often leads to significant direct and indirect health care costs — has been upended with the recent approval of three injectable monoclonal antibody products in a new preventive medication class that’s significantly more effective than older preventive migraine drugs, a researcher says.

These new calcitonin gene-related peptide (CGRP) inhibitors — Amgen, Inc. and Novartis AG’s Aimovig (erenumab), Teva Pharmaceuticals’ Ajovy (fremanezumab) and Eli Lilly and Co.’s Emgality (galcanezumab) — also may usher in an era of value-based contracting for migraine products, with plan sponsors willing to pay more to get better results, Machaon Bonafede, Ph.D., outcomes research practice leader at IBM Watson Health, told attendees Oct. 23 at the Academy of Managed Care Pharmacy Nexus annual meeting, AIS Health reported.

“Prior to the approval of CGRPs, migraine preventive therapy was characterized by poor treatment persistence and medication, frankly, because of use of products that were never developed for or intended to treat migraine,” Bonafede said.

Express Scripts Holding Co. already has inked a value-based deal for two of the three drugs in the new migraine class. The PBM’s new SafeGuardRx Migraine Care Value program, which starts April 1, will cover Aimovig and Emgality. It will include a comprehensive clinical care program with access to CGRP inhibitors. In addition, Express Scripts is offering what’s in effect a money-back guarantee for plan sponsors when a patient discontinues therapy in the first 90 days.

According to Institute for Clinical and Economic Review (ICER), it is reasonable for payers to develop prior authorization criteria to ensure prudent use of CGRP inhibitors. ICER also urged drug manufacturers to exercise restraint in pricing and price negotiation so that net prices for the new therapies align with added benefits.

These new medications have the potential to remake migraine treatment, the direct and indirect costs of which have been estimated at $36 billion annually in the U.S., Bonafede said. Indirect costs — such as lost productivity — can be difficult to capture and quantify, he added.

Perspectives on Proposed Part D Change

November 29, 2018

If the Trump administration gets its way, Medicare Part D plan sponsors may at some point be on the hook for a greater share of costs once beneficiaries reach the catastrophic phase of coverage for prescription drugs. While America’s Health Insurance Plans (AHIP) is opposed to the idea, experts tellAIS Health that the time may be ripe for such a change.

If the Trump administration gets its way, Medicare Part D plan sponsors may at some point be on the hook for a greater share of costs once beneficiaries reach the catastrophic phase of coverage for prescription drugs. While America’s Health Insurance Plans (AHIP) is opposed to the idea, experts tellAIS Health that the time may be ripe for such a change.

Beneficiaries enter the catastrophic coverage phase when, as of 2018, their “true out-of-pocket costs” exceed $5,000. Once in that phase, beneficiaries pay no more than 5% of the total cost for their drugs, while the federal government pays 80% and the Part D plan pays 15%.

In its fiscal year 2019 budget proposal, the Trump administration suggests increasing plans’ share of costs for catastrophic coverage from 15% to 80% and shifting Medicare’s share from 80% to 20%. More recently, CMS Administrator Seema Verma said during an Oct. 18 event that the change is one area in which Part D could be “updated and modernized.”

Sean Creighton, a vice president in Avalere Health’s policy practice, says the change is probably needed because health plans will soon bear very little risk in the upper end of the Part D benefit.

AHIP, however, says it “strongly disagrees with the basic premise of this proposal — that incentives alone will produce such cost reductions.” It argues that “plans are already fully incentivized to negotiate vigorously for lower costs” and “drug companies are incentivized to provide price concessions only when leverage exists.”

Creighton says it is possible that shifting more risk to plans could result in higher premiums. But as long as the beneficiary cost-sharing in the catastrophic phase remains the same, the proposed policy change is likely to be “sort of invisible” to members, he adds.

On the other hand, increasing plans’ risk will likely cause them to step up some of their price-negotiation practices, such as excluding drugs from formularies, changing tier placement of drugs, and using prior authorization and step therapy. “So it may lead to a situation where access to particular drugs may become more restricted as the plans seek to contain costs,” Creighton says.

Radar On Market Access: New Biosimilars Help Crohn’s Cost, but Boost Oversight Needs

November 27, 2018

New biosimilars for Janssen Biotech, Inc.’s Remicade (infliximab) have helped to moderate costs for Crohn’s disease as they’ve launched over the last two years, but plans still rely on utilization management strategies, including site-of-service programs, to keep the cost of treating the condition under control, experts tell AIS Health.

New biosimilars for Janssen Biotech, Inc.’s Remicade (infliximab) have helped to moderate costs for Crohn’s disease as they’ve launched over the last two years, but plans still rely on utilization management strategies, including site-of-service programs, to keep the cost of treating the condition under control, experts tell AIS Health.
Additional biosimilars — notably, three biosimilars for AbbVie Inc.’s Humira (adalimumab) — eventually will enter the marketplace as well, but the Humira biosimilars currently are mired in patent litigation and likely won’t launch until 2023, says April Kunze, Pharm.D., senior director, clinical formulary development and trend management strategy at Prime Therapeutics LLC.
Even though biosimilars don’t reduce the cost of care as much as generics, “more competition has led to decreases in costs,” Kunze says. Immunomodulator biosimilars Inflectra (infliximab-dyyb) and Renflexis (infliximab-abda) both have launched over the last two years in the U.S. — Pfizer Inc.’s Inflectra in late 2016 and Merck & Co. Inc.’s Renflexis in mid-2017.
Biologics represent the biggest slice of Crohn’s drug costs. Most of the non-biologic agents have generic equivalents available, while the biologics are dominated by brand name products, even though over the past year or so, infliximab biosimilars have introduced competition to Remicade, says Beckie Fenrick, Pharm.D., senior partner-consulting, RemedyOne.
Plans employ utilization management to ensure appropriate drug use — “the right drug for the right patient based on clinical guidelines,” Kunze says. “Selection of formulary agents will depend on their guideline recommendations, cost and utilization.”
Mesfin Tegenu, R.Ph., president of PerformRx, notes that prior authorization is required for the anti-TNF inhibitors and biologic products, and that generics are available for some of the products. Meanwhile, he adds, rebates traditionally have been used to reduce unit cost for expensive brand name products, which then lowers overall costs.
Fenrick says that in addition to prior authorization and care management, plans also may employ site-of-service strategies for the infused products, ensuring members have access to the medications in the most cost-effective sites. Finally, “payers are looking at indication-based contracts, given that many of the biologics have a variety of indications with varying levels of clinical efficacy,” Kunze says.

MMIT Reality Check on Ovarian Cancer (Nov 2018)

November 23, 2018

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

According to our recent payer coverage analysis for ovarian cancer 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 ovarian cancer treatments shows that across all drugs in the class, only an average of 17% of Medicare lives are not covered for at least one of the drugs.

Trends: The FDA in June expanded the label of Avastin (bevacizumab) to include its use in combination with carboplatin and paclitaxel, followed by Avastin as a single agent, for the treatment of stage III or stage IV epithelial ovarian, fallopian tube or primary peritoneal cancer following initial surgery resection. Via AIS Health.

Radar On Market Access: Prime PBM’s Studies Show Promise for Managing Opioids

November 20, 2018

Researchers from Prime Therapeutics LLC recently presented studies on two approaches to managing the use of opioid medications, AIS Health reported.

Researchers from Prime Therapeutics LLC recently presented studies on two approaches to managing the use of opioid medications, AIS Health reported.

In the first opioid study, Florida Blue, Prime and Walgreens piloted a program where pharmacists gave a one-page opioid safety guide to Florida Blue members whose claim histories showed high opioid and controlled substance use when they picked up opioid prescriptions from a Walgreens pharmacy. The guide explained safe use, safe storage, safe disposal and overdose prevention for opioids, and included information on naloxone, a treatment used to counter the effects of an opioid overdose.

The intervention group, of 753 Florida Blue commercially insured members with pharmacy benefits through Prime, was compared with a similar group who used a non-Walgreens pharmacy and did not get the safety guide. With the intervention, researchers found “a statistically significant four-fold increase in the likelihood of a member receiving naloxone the next time they picked up an opioid prescription.”

Prime says the collaboration between the plan, PBM and pharmacy shows it is possible to identify high-risk opioid utilizers and increase the dispensing of naloxone — in keeping with the FDA’s efforts to increase the antidote’s availability as a means to reduce opioid overdose deaths — through a targeted process.

“Prime is currently working with Walgreens to operationalize an expansion of this [safety guide] program,” says Patrick Gleason, Pharm.D., Prime’s senior director of health outcomes. “A broader rollout is expected in 2019.”

In the second study, Prime’s researchers set out to develop a high-dose opioid predictive modeling process for Medicare members to identify them early, before they become high-risk opioid users.

Prime says it determined that separate predictive models are needed for first-time opioid users vs. those already using the drugs, and this approach resulted in “highly accurate” predictive models scoring and ranking the Medicare members on their future likelihood of getting high-dose opioids.

“We will be incorporating opioid predictive modeling scoring and ranking into our Medicare clinical programs beginning in first quarter of 2019,” Gleason says.

MMIT Reality Check on Migraine (Nov 2018)

November 16, 2018

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

According to our recent payer coverage analysis for migraine 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 migraine treatments shows that about 42% of the covered lives under commercial formularies are restricted.

Trends: The launch of the CGRP inhibitors disrupts the current market dynamics, and it’s currently unclear if they will create a treatment step after generic products but before botulinum toxins or be treated roughly equal to botulinum toxins. Via AIS Health.