Formulary guidance and transparency from P&T to point of care

Radar On Market Access: New Administration's Stance on Copay Accumulators Remains Unclear

Posted by Leslie Small on Mar 30, 2021

Thanks to recent regulatory moves and the increasing prevalence of copay accumulator/maximizer programs, the tactics that payers use to counter drug manufacturer copay assistance continue to be a controversial topic in the health care sector, AIS Health reported.

Copay accumulators work by preventing any monetary assistance that pharmaceutical companies offer commercially insured patients from counting toward their deductible or out-of-pocket maximum. Their close cousin, copay maximizers, take the total amount of a manufacturer's copay offset program and divide it by 12, and that amount becomes the new monthly copayment for all patients on any given drug over the course of a year.

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Topics: Industry Trends, Market Access, Payer

Trends That Matter for New Heart Failure Drugs

Posted by Jane Anderson on Mar 25, 2021

Treatment for heart failure still relies significantly on tried-and-true generic drugs, but new brand-name entrants — including Novartis' Entresto (sacubitril/valsartan) and Amgen's Corlanor (ivabradine) — are important additions to prescribers' clinical arsenals against the high-mortality condition, industry insiders tell AIS Health.

"Generic heart failure drugs, including beta blockers, ACE inhibitors, and ARBs [angiotension receptor blockers] have historically been used and continue to be the backbone of therapy," says April Kunze, Pharm.D., senior director of clinical program development for Prime Therapeutics. "However, in the past few years, additional treatment options have become available. Entresto is now recommended as a first-line treatment option in patients with an ejection fraction <= 40%."
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Topics: Industry Trends, Market Access, Product Release, Data & Analytics

Radar On Market Access: Health Insurers May See Earnings Hit From COVID Vaccine Reimbursement Hike

Posted by Leslie Small on Mar 25, 2021

CMS has significantly boosted the amount that Medicare will pay for administering COVID-19 vaccines, a move that appears to be a positive development for health care providers and retail pharmacies but a potential headwind for commercial health insurers, AIS Health reported.

Previously, the national average Medicare payment rate for administering single-dose vaccines was $28, but CMS on March 15 increased that to $40. For two-dose vaccines, the rate rose from $45 to $80.

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Topics: Industry Trends, Data & Analytics, Payer

Radar On Market Access: How Will Subsidy Expansion Impact ACA Marketplaces?

Posted by Leslie Small on Mar 23, 2021

For an individual health insurance market that is already hitting its stride, the new pandemic relief legislation's expansion of Affordable Care Act (ACA) subsidies is yet another positive catalyst that should make the exchanges more attractive to insurers and customers alike, experts tell AIS Health.

Under the American Rescue Plan, which President Joe Biden signed into law on March 11, individuals who already qualified for premium tax credits under the ACA will see more generous financial aid. In addition, people who earn more than 400% of the federal poverty level (FPL) will be eligible for reduced premiums for the first time thanks to a provision that caps marketplace premiums at 8.5% of all enrollees' income.

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Topics: Industry Trends, Data & Analytics, Payer

Radar On Market Access: Orphan Drug Act Has Been Overused, A New Study Shows

Posted by Peter Johnson on Mar 18, 2021

A new study published in Health Affairs found that spending in the orphan drug category is overwhelmingly concentrated on so-called partial orphan drugs, which have both orphan and nonorphan indications. The study affirms growing concerns across the health care industry that drugmakers are misusing the orphan drug designation and introducing unwarranted cost into the drug channel, AIS Health reported.

The Orphan Drug Act of 1983 covers diseases that affect fewer than 200,000 people in the U.S., plus diseases that affect more than 200,000 people but are so expensive to treat that companies developing and marketing such therapies are not expected to recover their costs. With the designation, the FDA grants drugmakers expanded intellectual property and commercial rights intended to offset these steep costs.

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

Radar On Market Access: Ohio Names New Medicaid PBM, Sues One of Current Vendors

Posted by Leslie Small on Mar 16, 2021

Ohio recently cleared a key hurdle in its plan to revamp how Medicaid enrollees' pharmacy benefits are managed, choosing Gainwell Technologies as the single PBM that will replace big-name firms including Cigna Corp.'s Express Scripts, CVS Heath Corp.'s Caremark, UnitedHealth Group's OptumRx and Centene Corp.'s Envolve Pharmacy Solutions, AIS Health reported.

Although PBMs and insurers generally oppose state moves to carve out pharmacy benefits from their Medicaid managed care contracts, Ohio says it expects the new single-PBM approach will "drive transparency, reduce pharmacy costs and simplify provider administration."

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Topics: Industry Trends, Market Access, Payer

Trends That Matter for New Prostate Cancer Treatment

Posted by Angela Maas on Mar 11, 2021

People being treated for advanced prostate cancer now have a new oral option. On Dec. 18, the FDA approved Myovant Sciences GmbH’s Orgovyx (relugolix), a gonadotropin-releasing hormone (GnRH) receptor antagonist, to treat adults with advanced prostate cancer, AIS Health reported. Dosing for the drug is a loading dose of 360 mg on the first day of treatment and then 120 mg of the tablet once daily.

Treatment of advanced prostate cancer usually involves androgen deprivation therapy (ADT), and the current standard of care is luteinizing hormone-releasing hormone (LHRH) receptor agonists, such as leuprolide acetate, which is administered by a health care provider as an injection or implant. It is available as AbbVie Inc.’s Lupron Depot and Eligard from Tolmar Pharmaceuticals, Inc. to treat prostate cancer.
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Topics: Industry Trends, Market Access, Product Release, Data & Analytics

Radar On Market Access: Cigna's Evernorth to Acquire MDLive in Telehealth Expansion

Posted by Peter Johnson on Mar 11, 2021

Health insurers have begun to consolidate their position in the telehealth market, as indicated by a recent move by Cigna Corp. to acquire MDLive Inc. Meanwhile, lawmakers are beginning to consider the future of telehealth regulation and payment, AIS Health reported.

Cigna's Evernorth health services arm announced on Feb. 26 that it had reached an agreement with MDLive to acquire the virtual care provider, according to MDLive's website. MDLive has been available in-network as a primary care option to all members of Cigna's commercial plans since January 2020.

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Topics: Industry Trends, Data & Analytics, Payer

Radar On Market Access: FDA's Breyanzi Approval May Not Change NHL Management

Posted by Angela Maas on Mar 9, 2021

With the FDA's approval of Bristol Myers Squibb's Breyanzi (lisocabtagene maraleucel) last month, there are now three chimeric antigen receptor T cell (CAR-T) therapies to treat a certain type of non-Hodgkin’s lymphoma (NHL). A Zitter Insights poll shows that payers do not anticipate its approval as having much of an impact on their management of the space, AIS Health reported.

On Feb. 5, the FDA approved Breyanzi for the treatment of adults with relapsed or refractory large B-cell lymphoma after two or more lines of systemic therapy, including diffuse large B-cell lymphoma not otherwise specified, high-grade B-cell lymphoma, primary mediastinal large B-cell lymphoma and follicular lymphoma grade 3B.

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Topics: Industry Trends, Market Access, Product Release

Perspectives on Pass-Through Rebate Models

Posted by Peter Johnson on Mar 4, 2021

With the Trump administration's rebate rule delayed and possibly slated for repeal by Democrats in Congress, major changes in how the PBM industry distributes rebate revenue will have to come from the private sector, AIS Health reported.

The Biden administration will suspend implementation until 2023 of the so-called "rebate rule," a Trump administration regulation that would have revamped the Medicare prescription drug rebate system, and DC insiders expect the regulation will be repealed by Congress before then. Meanwhile, a growing number of PBMs that deal in the commercial market have pitched plan sponsors on a 100% pass-through rebate structure, in which the PBM collects its compensation through a fee or surcharges rather than diverting a share of rebate revenue.
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Topics: Industry Trends, Data & Analytics