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Radar On Market Access: CMS Extends Options to States to Test Innovative Dual-Eligible Care Models

May 9, 2019

Although independent evaluations of ongoing demonstrations to integrate care for dual-eligible Medicare-Medicaid beneficiaries are still underway, an April 24 letter from CMS Administrator Seema Verma signaled the agency’s commitment to proving the value of the models as well as testing alternatives, AIS Health reported.

Although independent evaluations of ongoing demonstrations to integrate care for dual-eligible Medicare-Medicaid beneficiaries are still underway, an April 24 letter from CMS Administrator Seema Verma signaled the agency’s commitment to proving the value of the models as well as testing alternatives, AIS Health reported.

In the letter to state Medicaid directors, CMS extended three new opportunities to “test state-driven approaches” for integrating duals’ care:

(1) For interested states with capitated Financial Alignment Initiative (FAI) model demos, CMS said it is “open to partnering on revisions.”

(2) For interested states without capitated demos, CMS said it welcomes interest in testing the model through new demos in additional states.

(3) CMS said it is open to partnering with states on testing new state-developed models to better serve dual eligibles and invited states to respond with ideas, concept papers and/or proposals.

Kevin Malone, a senior counsel in the Health Care and Life Sciences practice in the Washington, D.C., office of Epstein Becker & Green, P.C. and a former duals officer at CMS, predicts that, for states with existing demos, they will not only revisit their memoranda of understanding that outline the terms of their agreements with CMS, but will use it as a chance to amend their three-way contracts with CMS and plans. This presents a unique opportunity for the plans to suggest changes around certain programmatic requirements or provider training that may reduce some of their burden and streamline some of the technical details of their arrangements.

Radar On Market Access: Magellan Sees Success With Infliximab Biosimilars

May 7, 2019

Magellan Rx Management saw a significant shift in utilization from Janssen Biotech, Inc.’s Remicade (infliximab) to biosimilars after it implemented a comprehensive utilization management (UM) program, resulting in 34% drug cost savings, the PBM reported.

Magellan Rx Management saw a significant shift in utilization from Janssen Biotech, Inc.’s Remicade (infliximab) to biosimilars after it implemented a comprehensive utilization management (UM) program, resulting in 34% drug cost savings, the PBM reported.

The program, which began in late 2017, involves any patient prescribed an infliximab product for any indication, and is available to all payer clients as an opt-in option, Steve Cutts, senior vice president and general manager, tells AIS Health.

When Magellan Rx began the infliximab program in the fourth quarter of 2017, 100% of the PBM’s patients receiving an infliximab product received Remicade and none took biosimilars, the PBM said. In the third quarter of 2018, the last quarter for which Magellan has data, 86% of patients got the biosimilar and 14% took the brand-name drug.

The FDA approved the first infliximab biosimilar, Pfizer, Inc.’s Inflectra (infliximab-dyyb), in April 2016. The agency now lists three approved infliximab biosimilars: Inflectra; Merck & Co., Inc.’s Renflexis (infliximab-abda); and Pfizer’s Ixifi (infliximab-qbtx). Pfizer is not launching Ixifi in the U.S. since it already has Inflectra on the market, so only Inflectra and Renflexis are being sold in the U.S.

Magellan Rx works with both infliximab biosimilar manufacturers, Cutts says, and can “offer multiple options to our clients regarding which biosimilar or combination of biosimilars will work best for their unique situation.”

The Magellan Rx infliximab UM program aims to overcome reluctance on the part of physicians to prescribe biosimilars by emphasizing that they provide the same level of clinical efficacy and safety, with the added benefit of cost savings.

“Likely the most important factor [in the Magellan Rx utilization management program] is obtained provider acceptance that the biosimilar is going to deliver the same results as the innovator product,” says Daniel Malone, R.Ph., Ph.D., professor at the University of Arizona College of Pharmacy.

30 Years of Market Access: Highlights from Asembia

May 7, 2019

This year at #Asembia19, we celebrated 30 years of trusted market access insights at the Terrace Pointe Café in the Wynn Las Vegas. It was great to connect with our clients and community at the summit and our anniversary party.

As one company, we now combine innovative technology and trusted data with strong payer insights and oncology expertise. We are 100% focused on market access and are the #1 source of formulary, policy and restriction data for manufacturers and prescribers.

This year at #Asembia19, we celebrated 30 years of trusted market access insights at the Terrace Pointe Café in the Wynn Las Vegas. It was great to connect with our clients and community at the summit and our anniversary party.

As one company, we now combine innovative technology and trusted data with strong payer insights and oncology expertise. We are 100% focused on market access and are the #1 source of formulary, policy and restriction data for manufacturers and prescribers.

MMIT Reality Check on Low Testosterone (May 2019)

May 3, 2019

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

According to our recent payer coverage analysis for low testosterone 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 low testosterone treatments due to chronic kidney disease shows that under the pharmacy benefit, about 55% of the lives under commercial formularies are covered with utilization management restrictions.

Trends: In March 2019, the FDA approved Jatenzo (testosterone undecanoate) for the treatment of males with low testosterone levels because of specific genetic disorders or pituitary gland-damaging tumors. Via AIS Health.

Perspectives on New Postpartum Depression Drug

May 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.

Dea Belazi, Pharm.D., president and CEO of AscellaHealth, says 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. Moreover, 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.”