Provider

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: BioScrip, Option Care Will Join Forces Within Infusion Market

April 11, 2019

Two of the country’s largest independent infusion services providers recently unveiled that they have entered into a merger agreement. After coming together, BioScrip, Inc. and Option Care Enterprises, Inc. would be the No. 2 home/alternate site infusion provider in the United States, AIS Health reported.

Two of the country’s largest independent infusion services providers recently unveiled that they have entered into a merger agreement. After coming together, BioScrip, Inc. and Option Care Enterprises, Inc. would be the No. 2 home/alternate site infusion provider in the United States, AIS Health reported.

Under the terms of the deal, publicly traded BioScrip would issue new shares to Madison Dearborn Partners, LLC and Walgreens Boots Alliance, Inc., which are the Option Care shareholders, giving them 80% of BioScrip’s stock, with current BioScrip shareholders holding the remaining 20%. The new company would be publicly traded.

“Scale is critical to succeed in home infusion/alternate site services,” says Bill Sullivan, principal consultant for Specialty Pharmacy Solutions LLC. “Opportunity to build scale…is important for payer access and better cost-of-goods pricing through wholesalers and in some cases direct with manufacturers.”

“From the pharma side, I’m not going to say it’s easy from a distribution standpoint, but with limited-distribution drugs…and an entity that covers 96% of the U.S. population, it’s easy for a company to pick a partner like this,” says Pat Clifford, managing director at The Braff Group.

“Considering that the home/site infusion industry has been growing at two to three times the rate of U.S. GDP [i.e., gross domestic product], we think it is no surprise that a national player would emerge eventually,” remarks Bill Bolding, an analyst at Provident.

Benefits of the deal include the fact that “integrating patient care from outpatient through the home setting has the potential to improve outcomes significantly, all while minimizing the traditional waste/cost that comes with the patient transition,” Bolding tells AIS Health.

While cost cutting is an additional benefit of the arrangement, it also may prove to be a challenge, says Clifford. “In markets with duplicate locations,” they would be able to combine them, “but if they are overlapping a lot, some locations may need to be shut down.”

Another potential challenge is the fact that “no individual player has controlled 10%-25% [of the] infusion market to date, depending on how you measure the space,” says Bolding. “There is no playbook that this executive team can copy to merge site and home infusion at this scale, and as always, reimbursement risk should be considered.”

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.

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.