MMIT brings transparency and guidance to pharmacy and medical benefit information

Manage with confidence. Decide with information. Communicate with certainty.
MMIT

Trends That Matter for Parkinson’s Disease Medications

October 24, 2019

Although three new drugs for Parkinson’s disease have been approved over the last year, plans generally are sticking with the drugs they’ve included on formularies for several years, most of which are generic, experts tell AIS Health.

Although three new drugs for Parkinson’s disease have been approved over the last year, plans generally are sticking with the drugs they’ve included on formularies for several years, most of which are generic, experts tell AIS Health.

That may change in the long term as new gene therapies that currently are in development are approved and come online. But none of those potential new treatments are close to market right now, says Mesfin Tegenu, R.Ph., president of PerformRx.

“Many commonly used therapies for Parkinson’s disease — carbidopa-levodopa, MAO-Bs, dopamine agonists — have available generics, which on most plans would be considered formulary options, or one generic product within each class would be selected as formulary,” Tegenu tells AIS Health.

The FDA in August approved Kyowa Kirin, Inc.’s Nourianz (istradefylline) tablets as an add-on treatment to levodopa/carbidopa in adult patients with Parkinson’s disease experiencing motor fluctuations. In February, the FDA approved Osmotica Pharmaceutical US LLC’s Osmolex ER (amantadine) for the treatment of Parkinson’s disease. And in late December, the FDA approved Accorda Therapeutics’ Inbrija (levodopa inhalation powder) for intermittent treatment of off episodes in people with Parkinson’s disease taking carbidopa/levodopa.

Still, plans are stocking their formularies with less expensive generic medications. The graphics below show the current market access to Parkinson’s disease drugs for all payers under the pharmacy benefit and their utilization management restrictions.

Radar On Market Access: Low-Cost Enhanced PDP Offerings See Growth in 2020

October 24, 2019

When it comes to Medicare Part D stand-alone Prescription Drug Plans (PDPs) in 2020, experts say the most notable trend is the rising prevalence of lower-cost enhanced plan offerings, AIS Health reported.

When it comes to Medicare Part D stand-alone Prescription Drug Plans (PDPs) in 2020, experts say the most notable trend is the rising prevalence of lower-cost enhanced plan offerings, AIS Health reported.

According to CMS’s recently released landscape files, there will be a total of 1,433 PDP plans in 2020, up from 1,369 in 2019.

That increase is “mainly due to additional enhanced, low-premium plans being offered this year, both through existing carriers offering new plans, and then there’s also a new entrant to the national PDP market,” says Shelly Brandel, a principal and consulting actuary in the Milwaukee office of Milliman, Inc.

The new carrier, Clear Spring Health, will offer PDPs for the first time in 2020 in 41 states and Washington, D.C. Brandel notes that Clear Spring’s Premier Rx plans, an enhanced offering, have an average premium of around $15.

Also worth noting is that Humana Inc. created a new offering called the Humana Walmart Value Rx Plan. The premium for that plan is $13.20 across all states.

WellCare Health Plans, Inc., meanwhile, is offering the new WellCare Wellness Rx plan, an enhanced plan that has an average premium of about $14, according to Brandel.

In general, Brandel says, “the enhanced plans with low premiums have been an area of growth in the PDP market.”

A regulatory change in 2018 — which said plan sponsors no longer have to demonstrate that their enhanced PDPs offered in the same region are “meaningfully different” regarding enrollee out-of-pocket costs — likely made it easier for insurers to offer low-premium enhanced plans, Brandel says. However, “the main reason more of these plans are being offered is because they are popular with members,” she adds.

Across all PDP offerings, the projected average monthly basic Part D premium in 2020 will be $30 — the lowest it’s been since 2013, according to CMS.

Radar On Market Access: More Than 80% of Medicare Advantage Enrollees Are in High Star Plans, CMS Reports

October 22, 2019

According to CMS’s recent release of the 2020 star quality ratings, many Medicare Advantage beneficiaries continue to enroll in plans with 4 or more stars. There was also a notable shift of membership into highly rated Prescription Drug Plans, some of which made meaningful improvements on an individual basis even though PDP performance on average was stagnant, AIS Health reported.

According to CMS’s recent release of the 2020 star quality ratings, many Medicare Advantage beneficiaries continue to enroll in plans with 4 or more stars. There was also a notable shift of membership into highly rated Prescription Drug Plans, some of which made meaningful improvements on an individual basis even though PDP performance on average was stagnant, AIS Health reported.

More than half of Medicare Advantage Prescription Drug plans (210 contracts) that will be offered in 2020 earned overall star ratings of 4 or higher, compared with 46% of MA-PDs (172 contracts) offered in 2019, CMS reported on Oct. 11. Weighted by enrollment, approximately 81% of MA-PD enrollees are currently in contracts that will have 4 or more stars in 2020, up from about 75% in 2019.

Given that there were no substantial changes to the star measures in terms of weights or calculations this year, MA-PDs’ performance on average is “good evidence that the industry did a great job teaching to the test,” observes Melissa Smith, senior vice president of strategy and stars with Gorman Health Group.

Meanwhile, the percentage of enrollees in a PDP rated 4 or higher increased from a meager 3.5% in 2019 to approximately 28% for 2020 based on current enrollment, and the average star rating for PDPs rose from 3.34 in 2019 to 3.5 in 2020.

Individually, PDPs showed some significant performance increases, which Smith says may be attributable to pharmacy benefit managers “having really aligned services and offerings around their customers’ Part D star measure needs.”

On a measure level, MA-PDs showed improvements on 13 out of 33 Part C measures. And on the Part D measures, MA-PDs improved on eight measures, including on the three medication adherence measures. PDPs, meanwhile, performed better on average on 11 out of 14 measures.

MMIT Reality Check on Hepatocelluar Carcinoma (Oct 2019)

October 18, 2019

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

According to our recent payer coverage analysis for hepatocelluar carcinoma 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 hepatocelluar carcinoma treatments shows that under the pharmacy benefit, almost 55% of the lives under commercial formularies are covered with utilization management restrictions.

Trends: In May 2019, the FDA expanded the label of Cyramza (ramucirumab) to include the treatment of hepatocellular carcinoma in people with an alpha fetoprotein (AFP) of >400 ng/mL who previously were treated with Nexavar (sorafenib).

Perspectives on New Solutions to Finance High-Cost Treatments

October 17, 2019

With concerns mounting about how health plan sponsors will pay for breakthrough treatments with ultra-high price tags, some major insurers are offering up new solutions aimed at easing that burden, AIS Health reported.

With concerns mounting about how health plan sponsors will pay for breakthrough treatments with ultra-high price tags, some major insurers are offering up new solutions aimed at easing that burden, AIS Health reported.

Cigna Corp. “appears at the forefront” of initiatives to cope with super-high-cost drugs, as Citi analyst Ralph Giacobbe puts it, given that the firm recently introduced a new solution that would help clients pay for and manage two gene therapies: Luxturna and Zolgensma.

Members whose plan sponsors pay a per-member per-month fee for Cigna’s new solution — called Embarc Benefit Protection — will pay nothing out of pocket for Zolgensma or Luxturna if they meet the clinical qualifications to be treated with one of those therapies.

Steve Wojcik, vice president of public policy for the National Business Group on Health, says that “employers are looking for solutions like that from their health plan partners and the PBMs.” However, while offerings like Cigna’s could help employers “smooth out the spikes in expenses,” businesses remain concerned about the overall costs of breakthrough therapies in the pipeline, he notes.

Besides Cigna, other major names in the insurance sector, such as CVS Health Corp.’s Aetna and Anthem, Inc., are working on their own solutions to help cope with high-cost therapies, including annuity-style payment arrangements and value-based contracts.

David Dross, managed pharmacy practice leader at the consulting firm Mercer, says some large, self-insured employers that are concerned about ultra-costly treatments are rethinking their decision to forgo stop-loss coverage.

However, issues can arise if clinical and financial management of a high-cost drug are done separately, he adds. In other words, a plan sponsor may determine that a member qualifies for a high-cost drug, but the stop-loss carrier that’s taking on the financial responsibility may not agree.