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Radar On Market Access: Calif. Insurers Fear lll Effects if Medicaid Pharmacy Is Carved Out

May 2, 2019

California is quietly plowing ahead on plans by Gov. Gavin Newsom, a Democrat, to create a statewide bulk purchasing system for prescription drugs — and to transition pharmacy services for Medi-Cal, the state’s Medicaid program, from managed care to fee-for-service (FFS) by January 2021, AIS Health reported.

California is quietly plowing ahead on plans by Gov. Gavin Newsom, a Democrat, to create a statewide bulk purchasing system for prescription drugs — and to transition pharmacy services for Medi-Cal, the state’s Medicaid program, from managed care to fee-for-service (FFS) by January 2021, AIS Health reported.

In the latest development related to the initiatives, Los Angeles County tentatively has agreed “to sit at the same bargaining table” with Newsom’s administration to negotiate prices with drug manufacturers, the Los Angeles Times reported April 17.

The California Association of Health Plans (CAHP) says its main concerns relate to ongoing work on the Medi-Cal pharmacy services “carve-out.”

In its April 5 report, the state Legislative Analyst’s Office (LAO) says the state’s Medicaid pharmacy carve out plan likely will generate net savings to the state. But it notes many details have yet to be released concerning how the carve out will be implemented and how the administration believes it will affect Medi-Cal spending and stakeholders. Thus, the LAO recommends that “the Legislature withhold approval of future new state operations resources to implement the carve out until the administration provides key information that adequately answers major outstanding questions.”

According to CAHP spokesperson Mary Ellen Grant, the LAO report “says the state may save money [by shifting Medi-Cal’s pharmacy benefit from managed care to FFS], but there are a lot of trade-offs and even the savings are uncertain.”

She notes that analyses by The Menges Group and other researchers have found transitioning the drug benefit back to FFS would be costly to state Medicaid programs.

Radar On Market Access: Diabetic Drug’s Kidney Benefit May Not Be Game-Changer

April 30, 2019

The potential use of Invokana (canagliflozin) for chronic kidney disease as well as type 2 diabetes, its current indicated use, recently attracted national headlines. If Janssen Pharmaceuticals, Inc.’s supplemental indication for its medication is approved by the FDA, “it would be the first new treatment for diabetic kidney disease in decades,” the National Kidney Foundation said.

The potential use of Invokana (canagliflozin) for chronic kidney disease as well as type 2 diabetes, its current indicated use, recently attracted national headlines. If Janssen Pharmaceuticals, Inc.’s supplemental indication for its medication is approved by the FDA, “it would be the first new treatment for diabetic kidney disease in decades,” the National Kidney Foundation said.

The kidney foundation points out that diabetes is a key risk factor for chronic kidney disease. The group says it anticipates strong uptake of Invokana by clinicians and payers facing “high costs and management challenges” in treating advanced kidney disease in people with type 2 diabetes, AIS Health reported.

But Mesfin Tegenu, R.Ph., president of PerformRx, LLC, doesn’t expect a major impact on treatment. That’s because Invokana joins Jardiance (empagliflozin) and Farxiga (dapagliflozin), among others, in a class of type 2 diabetes medications called SGLT2 inhibitors — and some rival products already provide similar benefits, he says.

In 2018, the American Diabetes Association and European Association for the Study of Diabetes issued a consensus statement that “already recommends Jardiance in diabetic CKD [i.e., chronic kidney disease] patients due to the renal benefit,” Tegenu adds.

In the recently announced results for Invokana’s CREDENCE study, Invokana was found to reduce the risk of dialysis or the need for a kidney transplant, which Tegenu says is “good news for plan payers and patients since in addition cardiovascular benefits were also found.”

“However,” he adds, “[cardiovascular] benefits have been known for at least a year and guidelines already recommend these drugs in [chronic kidney disease] patients.”

MMIT Reality Check on Anemia — Chronic Kidney Disease (Apr 2019)

April 26, 2019

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

According to our recent payer coverage analysis for anemia treatments due to chronic kidney disease, 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 anemia treatments due to chronic kidney disease shows that under the pharmacy benefit, more than 56% of the lives under commercial formularies are covered with utilization management restrictions.

Trends: In October 2018, UnitedHealthcare said that starting Jan. 1, 2019, it would require step therapy prior authorization for Part B covered items that are not preferred for new starts. The plan will prefer biosimilar Retacrit (epoetin alfaepbx) over Procrit (epoetin alfa) and Aranesp (darbepoetin alfa). Via AIS Health.

Trends That Matter for Insulin

April 25, 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.

Leading PBMs, such as CVS Health Corp., Express Scripts and Prime Therapeutics, also applied formulary strategies to keep insulin affordable. CVS Health reported a -1.7% trend for antidiabetic drugs in 2018, despite increasing utilization and 5.6% average wholesale price inflation for brand drugs, according to its 2018 drug trend report.

By removing Lantus and Toujeo from the formulary and making Basaglar preferred, CVS reported its clients saw a 21.7% reduction in cost per long-acting insulin prescription, which translated to a lower overall cost of $0.34 per member per month.

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.

Radar On Market Access: CMS Guidance on Rebate Shift Offers Transition for Part D Plans

April 25, 2019

As insurers and PBMs prepared to submit their comments about a proposed overhaul of the prescription drug rebate system, CMS on April 5 issued a guidance document aimed at mitigating at least some of their concerns, AIS Health reported.

As insurers and PBMs prepared to submit their comments about a proposed overhaul of the prescription drug rebate system, CMS on April 5 issued a guidance document aimed at mitigating at least some of their concerns, AIS Health reported.

The proposed rule would remove safe-harbor protections under the federal anti-kickback statute for rebates paid by drug manufacturers to PBMs, Part D plans and Medicaid managed care organizations, and it would create a new safe-harbor protection for point-of-sale drug discounts.

The guidance states that if the administration sticks with its proposed 2020 implementation date for the rule, CMS will “conduct a demonstration that would test an efficient transition for beneficiaries and plans to such a change in the Part D program.” The voluntary demonstration would involve modifying Part D risk corridors so that the government “will essentially take 95% of the risk off the table” for plan sponsors, as Citi analyst Ralph Giacobbe put it.

Giacobbe advised that the memo appears “favorable to the largest PDP players,” including CVS Health Corp., UnitedHealth Group and Humana Inc., and “generally positive for PBMs and health insurers broadly.” He also wrote that “we’d guess everyone would participate” in the two-year Part D demonstration that the administration offered.

But Deb Devereaux, senior vice president of pharmacy at Gorman Health Group, says that may not necessarily be the case.

“It’s mainly fear of the unknown,” she says, when asked why plans might not opt in to the demonstration. Overall, the combination of the pending rebate rule with other new Medicare regulations is making for a tough landscape for insurers, she adds.