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

Trends That Matter: Centene's ACA Expansion

Posted by Leslie Small on Dec 17, 2020

Centene Corp., which has come to dominate the Affordable Care Act exchange market by continuing to expand even when other carriers pulled back, is facing more competition now that the market has stabilized and insurer participation has increased, AIS Health reported.

Given that dynamic, Citi analyst Ralph Giacobbe advised investors recently that he was placing a "negative catalyst watch" on Centene due to the new competitive pressures it's facing. Centene, he observed, "was displaced as the lowest priced plan in a number of markets," and so the insurer "will have to rely on retention and new market entry to offset competitive pressures, which could prove challenging and may stunt growth relative to expectations."
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Topics: Industry Trends, Data & Analytics, Payer

Radar On Market Access: New-to-Market Oral Drugs May Not Always Have a Leg Up on Injectables

Posted by Leslie Small on Dec 17, 2020

In its latest quarterly Drug Pipeline Insights Report, OptumRx includes a diverse array of medications that the UnitedHealth Group-owned PBM believes are likely to make a market impact when they're approved by the FDA, AIS Health reported. One interesting trend that applies to three of the five highlighted drugs is the fact that each is the first oral option in its respective category.

While oral medications tend to be thought of as more convenient than injectable or IV-administered therapies, that factor alone may not confer as much of a competitive advantage as one might think, according to one OptumRx executive.

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Topics: Specialty, Industry Trends, Market Access, Product Release

Radar On Market Access: First Round of Vaccines Are Expected to Be Free to the Public

Posted by Leslie Small on Dec 15, 2020

With FDA issuing emergency use authorization to the coronavirus vaccine from Pfizer Inc. and BioNTech last week and Moderna Inc.'s offering not far behind, in the coming months there will undoubtedly be a variety of vaccines being administered to Americans, AIS Health reported. But who will be paying for them?

"In the case of the COVID-19 vaccine, there is a very simple take-home message, which is that no one going to get the vaccine will be charged for the vaccine or its administration, no matter what type of insurance they have, or whether they have insurance at all," Karyn Schwartz, a senior fellow at the Kaiser Family Foundation (KFF), said during a Dec. 3 web briefing.

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Topics: Industry Trends, Market Access, Product Release, Payer

Perspectives on Biden Administration's Drug-Pricing Moves

Posted by Leslie Small on Dec 10, 2020

As is the case for other flavors of health care reform, President-elect Joe Biden's chance of passing substantial, transformative drug-pricing legislation is now highly dependent upon whether Democrats can eke out a majority in the Senate. While that question won't be resolved until Georgia completes runoff elections in January, industry observers point out that there are still ways that a Biden administration can address drug pricing, AIS Health reported.

"A president can do a lot even with a divided Congress," says Stephanie Kennan, a member of McGuireWoods Consulting's federal public affairs group. "Part of how well something gets done…depends upon the skills of the president or those negotiating for him. With Biden perhaps having a better understanding of the Senate, having come from the Senate, [that] might help him."
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Topics: Industry Trends, Payer

Radar On Market Access: Employers Show Interest in Moving to ICHRAs

Posted by Peter Johnson on Dec 10, 2020

Health care industry insiders say that employers of all sizes are beginning to take a serious look at moving some of their health benefits to Individual Coverage Health Reimbursement Arrangements (ICHRAs) starting in 2022, AIS Health reported.

In July 2019, the Trump administration finalized new regulations for ICHRAs, giving employers greater flexibility to reimburse qualifying employees buying health insurance policies on the individual market.

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Topics: Industry Trends, Payer

Radar On Market Access: Insurers Will Play Key Role in COVID Vaccine Distribution, Reimbursement

Posted by Brian Eastwood on Dec 8, 2020

As details continue to emerge about the availability of COVID-19 vaccines and how they will be administered, the role that payers will play in the process is becoming clearer, AIS Health reported.

It's imperative for health plans to do two key things at the same time, according to Katherine Dallow, M.D., the vice president of clinical programs and strategy at Blue Cross Blue Shield of Massachusetts. Payers need to help the entities that will be distributing the vaccine to identify the individuals who should be first in line to be vaccinated, and they need to use their resources to help educate the community.

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Topics: Industry Trends, Product Release, Payer

Trends That Matter for Growth Hormone Deficiency Treatments

Posted by Angela Maas on Dec 3, 2020

When the FDA approved Novo Nordisk, Inc.'s Sogroya (somapacitan-beco) for the replacement of growth hormone in adults with growth hormone deficiency on Aug. 28, it became the only long-acting agent on the market, AIS Health reported.

There are seven short-acting growth hormones currently available to treat adults with growth hormone deficiency, all of them branded forms of somatropin. Differences among the products, all of which are self-administered, include the strengths available and the type of device to deliver the treatment. But all of them must be administered daily. Sogroya, which also is self-administered, is the only FDA-approved product with weekly dosing.
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Topics: Industry Trends, Data & Analytics, Payer

Radar On Market Access: For PBMs, Amazon Pharmacy May Pose Only Indirect Threat

Posted by Leslie Small on Dec 3, 2020, Inc. made a splash in the health care world on Nov. 17 when the online retail powerhouse unveiled new pharmacy offerings that aim to disrupt the prescription drug market with increased convenience and savings, AIS Health reported.

In addition to setting up its own online pharmacy, Amazon is partnering with one of the three largest PBMs — Cigna Corp.'s Express Scripts — to offer a prescription-savings benefit that will be available to Amazon Prime members. "It can be used for discounts up to 80% off generic and 40% off brand name medications at over 50,000 participating pharmacies nationwide," according to a press release.

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Topics: Industry Trends

Perspectives on CMS Insulin Demo

Posted by Leslie Small on Nov 26, 2020

In 2021, about half of enhanced stand-alone Prescription Drug Plans (PDPs) and a little more than a third of Medicare Advantage-Prescription Drug (MA-PD) plans will participate in a new demonstration that aims to lower diabetic seniors' out-of-pocket costs by capping copays at $35 for a broad set of insulin products, according to a new analysis by consulting firm Avalere Health.

Among the 310 enhanced PDPs that opted to participate in CMS's Part D Senior Savings Model for 2021, the average enrollment-weighted premium is $57.53 — $23.46 higher than the average premium for non-participating plans, the analysis found. But in the MA-PD space, the average enrollment-weighted premium for the 1,287 participating plans is $10.36 less than the cost of non-participating plans ($22.74 versus $33.10).
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Topics: Industry Trends, Data & Analytics, Payer

Radar On Market Access: Teledermatology Program Reduces Patient Wait Time But Doesn't Increase Utilization

Posted by Jane Anderson on Nov 26, 2020

A pilot telemedicine program dramatically reduced the amount of time it took for primary care physicians to consult with dermatologists on skin ailments but did not increase utilization or cost, according to a new study from Independence Blue Cross and the University of Pennsylvania, AIS Health reported.

"Dermatology is an ideal specialty for telemedicine due to the visual nature of the clinical assessment," says study co-author Aaron Smith-McLallen, director of health informatics and advanced analytics at Independence Blue Cross. "Using telemedicine, patients can get quality care very quickly and reduce wait times for patients with more acute needs that are not suitable for telemedicine intervention."

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Topics: Industry Trends, Data & Analytics, Payer