Under the direction of its new governor, Democrat Gavin Newsom, California is planning to take control of the pharmacy benefit for all of the state's Medi-Cal beneficiaries, AIS Health reported.

 

Medi-Cal, California's Medicaid program, is served by more than 20 managed care organizations. MCOs are currently able to contract with a pharmacy benefits manager, but the new plan would allow the state to directly negotiate drug prices, purchase drugs in bulk and develop transparency on drug cost reimbursement.

 

Topics: Specialty, Data & Analytics

After Highmark Health expanded from an insurer to an integrated delivery system, the organization decided it was uniquely positioned to launch a platform to test early-stage, FDA-approved medical innovations that were struggling to attain the evidence needed for widespread adoption — and, critically, insurance reimbursement, AIS Health reported.

Nearly four years later, Highmark Health Plan and its affiliate Allegheny Health Network have changed their policies and purchasing contracts to provide therapeutic innovations to members after gathering evidence on their effectiveness. Examples include HeartFlow, which can create a 3D model of coronary arteries and blockages, and FreeSpira, a digital therapeutic that reduces debilitating panic attacks.

 

Topics: Data & Analytics, Provider, Payer

Payers typically use tools such as prior authorization and utilization review to manage cystic fibrosis treatments, but PBM experts say they are on the cusp of implementing more innovative strategies that might help to improve adherence while addressing the cost of cystic fibrosis drugs, AIS Health reported.

Cystic fibrosis, an inherited chronic disease that attacks the lungs and digestive organs, is caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. CFTR modulators and other therapies carry a high price tag, typically costing $250,000 to $368,000 per year. Other drugs, most of which do not have generic equivalents, can add tens of thousands of dollars to that total.

 

Topics: Specialty, Industry Trends, Product Release, Provider, Payer

According to our recent payer coverage analysis for HIV 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.

Topics: Specialty, Market Access, Payer, Branding & Marketing

Under the direction of its new governor, Democrat Gavin Newsom, California is planning to take control of the pharmacy benefit for all of the state's Medi-Cal beneficiaries — the vast majority of which currently have that part of their care administered by private insurers and their PBMs, AIS Health reported. What's more, the order directs state agencies to create bulk-purchasing arrangements for high-priority drugs and establish a framework for letting private businesses and insurers join the state’s buying pool.

The idea of the state's Medicaid program shifting to an entirely fee-for-service drug benefits system is already sparking worries about what it will do to PBMs' bottom lines.

 

Topics: Industry Trends, Provider, Payer

Nearly two weeks after the Trump administration issued a proposed rule that would effectively overhaul the prescription drug rebate system, the dust has still not settled in the PBM sector as firms brace for a seismic shift in how they do business, 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. It would also create two new safe harbors: one for prescription drug discounts offered directly to patients, and one for fixed-fee service arrangements between drug manufacturers and PBMs.  

 

Topics: Industry Trends, Market Access, Provider, Payer

For its first annual drug trend report as a part of Cigna Corp., Express Scripts Holding Co. said it had achieved a record low drug trend of 0.4% across its clients' employer-sponsored commercial plans in 2018. Overall, the PBM reported savings of $45 billion for its clients last year, AIS Health reported.

The PBM cited "an unprecedented 0.3% decline" in per-beneficiary drug spending across Medicare plans. Overall, there was a 1.4% decrease in unit cost trend, which allowed clients to absorb a 1.1% increase in utilization, the PBM said. Oncology replaced diabetes as Medicare’s top therapy class by per member per year spend.

 

Topics: Industry Trends, Market Access, Data & Analytics, Provider, Payer

According to our recent payer coverage analysis for rheumatoid arthritis (RA) 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.

Topics: Specialty, Market Access, Payer, Branding & Marketing

The specialty pharmacy and infusion therapy spaces have certainly seen their share of merger and acquisition (M&A) activity over the years. Some challenges within those industries may have helped slow down 2018 activity a bit, observes Reg Blackburn, managing director at The Braff Group. And for 2019, we may see more of the same, AIS Health reported.

As far as specialty pharmacy trends in 2018, Blackburn points out that "the largest specialty pharmacies continue to get even larger. Payer- and chain-owned dominate. Most new entity growth is coming from large academic hospitals starting their own specialty pharmacies."

 

Topics: Specialty, Industry Trends, Product Release, Data & Analytics

With the FDA approving multiple novel new therapies over the past couple of years, we should expect to see more of the same moving forward. But that innovation is not cheap, and the pharmaceutical industry likely will continue to offer products at higher price points than ever before, AIS Health reported.

As payers struggle to rein in high specialty drug prices, many have turned to copay accumulator programs, and this trend shows no signs of slowing. "There was an increased focus on copay accumulator programs in 2018," comments Amy Nash, Pharm.D., president of RelianceRx, the specialty pharmacy affiliate of Independent Health. She tells AIS Health she expects to see "further refinement of copay accumulator programs from payers and additional strategies from pharma to prevent them."

 

Topics: Specialty, Industry Trends, Product Release, Provider, Payer