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Radar On Market Access: CBO Says Proposed Rebate Rule Will Cost Government $177B

Posted by Angela Maas on May 14, 2019

When HHS unveiled a proposed rule in late January aimed at eliminating drug rebates in Medicare Part D and Medicaid managed care, the proposal was met with mixed responses. A recently released score from the Congressional Budget Office (CBO) calls into question whether the administration chooses to move forward with the proposal in its current form, AIS Health reported.

The proposal would do away with the safe harbor protection in the anti-kickback statute for rebates negotiated between manufacturers and PBMs starting Jan. 1, 2020.
 
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Topics: Industry Trends, Data & Analytics, Provider, Payer

Radar On Market Access: CMS Extends Options to States to Test Innovative Dual-Eligible Care Models

Posted by Lauren Flynn Kelly on May 9, 2019

Although independent evaluations of ongoing demonstrations to integrate care for dual-eligible Medicare-Medicaid beneficiaries are still underway, an April 24 letter from CMS Administrator Seema Verma signaled the agency's commitment to proving the value of the models as well as testing alternatives, AIS Health reported.

In the letter to state Medicaid directors, CMS extended three new opportunities to "test state-driven approaches" for integrating duals' care:
 
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Topics: Industry Trends, Provider, Payer

Radar On Market Access: Magellan Sees Success With Infliximab Biosimilars

Posted by Jane Anderson on May 7, 2019

Magellan Rx Management saw a significant shift in utilization from Janssen Biotech, Inc.'s Remicade (infliximab) to biosimilars after it implemented a comprehensive utilization management (UM) program, resulting in 34% drug cost savings, the PBM reported.

The program, which began in late 2017, involves any patient prescribed an infliximab product for any indication, and is available to all payer clients as an opt-in option, Steve Cutts, senior vice president and general manager, tells AIS Health.
 
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Topics: Industry Trends, Market Access, Data & Analytics, Provider, Payer

Perspectives on New Postpartum Depression Drug

Posted by Judy Packer Tursman on May 2, 2019

The FDA's recent approval of the first medication specifically aimed at treating postpartum depression is drawing a favorable response from clinicians, while payers could face challenges.

PBM executives tell AIS Health that the postpartum depression drug, Zulresso (brexanolone) injection, is likely to be covered under the medical, not the pharmacy, side of the benefit.
 
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Topics: Specialty, Industry Trends, Product Release, Provider, Payer

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

Posted by Judy Packer Tursman on 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.

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.
 
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Topics: Specialty, Industry Trends, Provider, Payer

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

Posted by Judy Packer Tursman on Apr 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 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.
 
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Topics: Product Release, Provider, Payer

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

Posted by Leslie Small on Apr 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.

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.
 
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Topics: Specialty, Industry Trends, Provider, Payer

Radar On Market Access: Copay Accumulators’ Use Rises; Virginia Passes Law Banning Such Programs

Posted by Angela Maas on Apr 23, 2019

Payers are continuing to implement copay accumulators and copay maximizers in an effort to counter copay assistance from pharmaceutical manufacturers, according to a recent survey, AIS Health reported.

A Zitter Insights report shows that more than 90 million commercial lives are covered by payers that have a copay accumulator program — and it doesn't look like these arrangements are going away any time soon.
 
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Topics: Industry Trends, Market Access, Provider, Payer

2019 Specialty Pharmacy Patient Choice Awards Finalists Announced

Posted by Matt Breese on Apr 23, 2019

 

The Specialty Pharmacy Patient Choice Award was created to recognize specialty pharmacies and their commitment to patient satisfaction. The criteria for this award were formulated by a committee comprised of individuals representing pharmaceutical manufacturers, health plans, pharmacy benefit managers (PBMs), trade organizations, consultants and equity research firms.

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

Perspectives on Insulin Management

Posted by Leslie Small on Apr 18, 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.

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