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Radar On Market Access: States Plow Ahead on ‘Subscription’ Models for Hep C Therapy

July 3, 2019

Last month, CMS approved Medicaid state plan amendments for Louisiana and Washington state, thus allowing the states to launch innovative value-based purchasing arrangements. Both states’ programs are aimed at working with partnering drug manufacturers to better handle the high costs for curative hepatitis C treatments, and may be the harbinger of similar initiatives by additional states.

Last month, CMS approved Medicaid state plan amendments for Louisiana and Washington state, thus allowing the states to launch innovative value-based purchasing arrangements. Both states’ programs are aimed at working with partnering drug manufacturers to better handle the high costs for curative hepatitis C treatments, and may be the harbinger of similar initiatives by additional states.

Louisiana “put the bow” on its plan to get hepatitis C treatment to Medicaid enrollees and incarcerated individuals over the next five years via a “Netflix”-like subscription model, a state official tells AIS Health.

On June 26, CMS approved Louisiana’s Medicaid state plan amendment authorizing the state to negotiate supplemental rebate agreements from prescription drug manufacturers, using a “modified subscription” model that initially focuses on antiviral agents for hepatitis C.

Meanwhile, Washington state was scrambling to finalize its agreement with AbbVie in time to launch its hepatitis C subscription-model program for Medicaid by July 1. On June 12, CMS gave the green light to Washington state’s Medicaid state plan amendment proposal to negotiate supplemental rebate agreements involving value-based purchasing arrangements with drug manufacturers.

“It’s clear from the recent developments in Washington [state] and Louisiana that payers are looking for innovative ways to pay for the increasing number of promising but costly medications coming to market, including the curative Hep C therapies,” Academy of Managed Care Pharmacy Chief Operating Officer Cynthia Reilly said in a statement to AIS Health.

“The subscription model is one of several models being implemented in real-world settings,” Reilly said. “It’s hard to say if it will become the dominant model. It’s more likely that we will continue to see experimentation and refinements, including with subscription-based, value-based and outcomes-based models.”

Radar On Market Access: New York Bill Targets on Pricing Transparency from PBMs

July 2, 2019

Lawmakers in New York in June approved wide-ranging legislation designed to require pricing transparency from PBMs and to eliminate key PBM practices. But the bill could potentially limit plans’ ability to respond to pricing moves by manufacturers, one consultant tells AIS Health.

Lawmakers in New York in June approved wide-ranging legislation designed to require pricing transparency from PBMs and to eliminate key PBM practices. But the bill could potentially limit plans’ ability to respond to pricing moves by manufacturers, one consultant tells AIS Health.

The New York bill (S.B. 6531) would require that PBMs disclose key pricing and rebate information and pass through all rebates and discounts to the plans and payers, and that they act in the best interests of the covered individual and the health plan or provider.

The New York Health Plan Association, which did not support the legislation, is particularly concerned with the “best interests” section, which imposes a fiduciary relationship on PBMs “in all but name,” says Ashley Stuart, director of government affairs for the association.

The legislation also would prohibit mid-year formulary changes and drug substitutions, and it would require PBMs operating in the state to be licensed beginning next year.

Josh Golden at Arthur J. Gallagher & Co.’s Solid Benefit Guidance says, “formulary strategies are designed to help keep drug costs in check. In moving forward with this legislation, the state potentially limits the ability of health plans to apply pricing pressure on pharmaceutical manufacturers throughout the year.”

More generally, the legislation will lead to higher health insurance premiums for employers and consumers, warned New York Health Plan Association President and CEO Eric Linzer in a statement.

The legislation comes at a time when several states are considering efforts to rein in PBMs. “At least four or five states are looking at the impact of Medicaid [pharmacy benefit] price transparency,” says Alex Shekhdar, founder of Sycamore Creek Healthcare Advisors. “It goes back to the larger fundamental conversation of what states should be looking at — they recognize there’s money under the table, especially in the PBM space.”

MMIT Reality Check on Acute Lymphoblastic Leukemia (Jun 2019)

June 28, 2019

According to our recent payer coverage analysis for acute lymphoblastic 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 lymphoblastic 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 lymphoblastic leukemia treatments shows that under the pharmacy benefit, about 42% of the lives under commercial formularies are covered with utilization management restrictions.

Trends: Kymriah is the first FDA-approved CAR-T cell therapy indicated for patients up to 25 years of age with relapsed or refractory B-cell ALL. Most payers list Kymriah as a drug that needs prior authorization, because a number of restrictions exist when using this medication.

Perspectives on Express Script’s “Digital Health Formulary”

June 27, 2019

Cigna Corp.’s Express Script PBM expects to introduce the industry’s first stand-alone “digital health formulary” in 2020, the company said May 16. It intends to use a uniform review process to ensure the safety and quality of apps and devices on the market for diabetes, cardiovascular and pulmonary conditions and behavioral health, AIS Health reported.

Cigna Corp.’s Express Script PBM expects to introduce the industry’s first stand-alone “digital health formulary” in 2020, the company said May 16. It intends to use a uniform review process to ensure the safety and quality of apps and devices on the market for diabetes, cardiovascular and pulmonary conditions and behavioral health, AIS Health reported.

By creating a digital formulary, Express Scripts “is using old hat methods to manage these new digital health solutions much like they do on brand and generic drugs or other therapies via utilization management,” says Nathan Ray, senior principal in business consulting firm West Monroe Partners’ health care and life sciences practice.

“A formulary allows the administrator to steer demand and control reimbursement for the use of preferred solutions,” Ray says. “Management via formulary has its upsides: It can reduce prices paid by payers and consumers.”

Moreover, digital health might be only the first step as PBMs ask what else they can put through their channel, says Ashraf Shehata, a principal in KPMG’s health care life sciences advisory practice and the firm’s Global Healthcare Center of Excellence.

Dea Belazi, Pharm.D., president and CEO of AscellaHealth, says it makes sense to think of the formulary pharmacy and therapeutics process as a coordinated effort to evaluate the merits of drugs or technologies — or for broader applications.

Yet “at the end of the day, how is this any different than what they’re doing today?” he asks. “Is there going to be an impact in either cost or outcomes in this new digital formulary process? Are numbers going to be different? It would be amazing” if there were improvements.

Radar On Market Access: CMS Requires Part D Plans to Offer RTBT

June 27, 2019

CMS in a final Medicare Advantage and Part D drug pricing rule posted last month may have notably walked back proposals around “protected” drug classes and pharmacy price concessions, but the agency finalized the requirement that Part D sponsors implement an electronic Real-Time Benefit Tool (RTBT). While the tool offers the potential to accelerate electronic prescribing, improve formulary adherence and lower prescription drug spending, it may pose a heavy information technology burden for some plans and require effort on the part of plans to encourage prescriber adoption, AIS Health reported.

CMS in a final Medicare Advantage and Part D drug pricing rule posted last month may have notably walked back proposals around “protected” drug classes and pharmacy price concessions, but the agency finalized the requirement that Part D sponsors implement an electronic Real-Time Benefit Tool (RTBT). While the tool offers the potential to accelerate electronic prescribing, improve formulary adherence and lower prescription drug spending, it may pose a heavy information technology burden for some plans and require effort on the part of plans to encourage prescriber adoption, AIS Health reported.

According to the rule, each Part D sponsor must implement at least one RTBT capable of integrating with at least one prescriber’s e-prescribing system or electronic health record (EHR) to “provide prescribers who care for its enrollees complete, accurate, timely and clinically appropriate patient-specific real-time formulary and benefit (F&B) information (including cost, formulary alternative and utilization management requirements)” by Jan. 1, 2021.

For proponents of e-prescribing like Point-of-Care Partners, LLC, the new requirement is “really exciting,” says Tony Schueth, CEO and managing partner of the health IT management consulting firm. “We have been trying to include formulary in the e-prescribing process for a long time, and the way we were doing formulary in the past just wasn’t patient-specific enough. So we’re at a really important juncture in the evolution of electronic prescribing and the benefit information being integrated.”

Heidi Harmon, a senior consultant with Gorman Health Group, says pushing back the start date of the RTBT to 2021 was very good news for plans because it will involve a “massive IT undertaking.” CMS had originally proposed that sponsors have the tool ready by Jan. 1, 2020, but pushed back the deadline after hearing from concerned stakeholders, the majority of which suggested delaying the start date until an industry standard becomes available. Harmon also notes that the requirement that a plan have a tool that can work with one prescriber’s system could be interpreted as one prescriber group’s system.