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

Radar On Market Access: CMS's Second Swing at Part D Protected Classes Might Work

Posted by Leslie Small on Dec 4, 2018

On Nov. 26, CMS issued a proposed rule that would let Medicare Advantage and Part D plans limit coverage of certain drugs in the six "protected classes," which include antidepressants, antipsychotics, anticonvulsants, immunosuppressants for treatment of transplant rejection, antiretrovirals and antineoplastics, AIS Health reported.

Under CMS's Contract Year 2020 Medicare Advantage and Part D Drug Pricing Proposed Rule, plans would be able to:
Read More

Topics: Industry Trends, Provider, Payer

Perspectives on Proposed Part D Change

Posted by Leslie Small on Nov 29, 2018

If the Trump administration gets its way, Medicare Part D plan sponsors may at some point be on the hook for a greater share of costs once beneficiaries reach the catastrophic phase of coverage for prescription drugs. While America's Health Insurance Plans (AHIP) is opposed to the idea, experts tell AIS Health that the time may be ripe for such a change.

Beneficiaries enter the catastrophic coverage phase when, as of 2018, their "true out-of-pocket costs" exceed $5,000. Once in that phase, beneficiaries pay no more than 5% of the total cost for their drugs, while the federal government pays 80% and the Part D plan pays 15%.

Read More

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

Radar On Market Access: Count on Trump Admin, not Congress, for Drug-Price Action

Posted by Leslie Small on Nov 22, 2018

In the wake of the 2018 midterm elections — which handed Democrats control of the House of Representatives — President Trump said he hoped to work with lawmakers on the other side of the aisle to lower the cost of prescription drugs.

Some industry analysts, though, are skeptical that sentiment will be enough to enact meaningful change, at least on the legislative front, AIS Health reported.
Read More

Topics: Industry Trends, Provider

Radar On Market Access: Prime PBM's Studies Show Promise for Managing Opioids

Posted by Judy Packer Tursman on Nov 20, 2018

Researchers from Prime Therapeutics LLC recently presented studies on two approaches to managing the use of opioid medications, AIS Health reported.

In the first opioid study, Florida Blue, Prime and Walgreens piloted a program where pharmacists gave a one-page opioid safety guide to Florida Blue members whose claim histories showed high opioid and controlled substance use when they picked up opioid prescriptions from a Walgreens pharmacy. The guide explained safe use, safe storage, safe disposal and overdose prevention for opioids, and included information on naloxone, a treatment used to counter the effects of an opioid overdose.

Read More

Topics: Industry Trends, Payer, Specialty, Provider, Data & Analytics

Perspectives on MA Plans’ Use of Step Therapy in Part B

Posted by Angela Maas on Nov 15, 2018

While many stakeholders have praised CMS's move to allow Medicare Advantage (MA) plans to apply step therapy to drugs covered under Part B, others have cautioned that it could result in delays or restrictions in patients accessing much-needed medications, AIS Health reported.

On Aug. 7, CMS issued new guidance allowing MA plans to use step therapy for Part B drugs as of Jan. 1, 2019. The letter also states that those MA plans that also offer prescription drug coverage may use step therapy to have a beneficiary use a drug under Part D before stepping to one under Part B.

Read More

Topics: Payer, Specialty, Industry Trends, Data & Analytics, Provider

Radar On Market Access: CVS, Cigna Preview What’s in Store After Their Deals Close

Posted by Leslie Small on Nov 13, 2018

CVS Health Corp. — which is on the brink of closing its $69 billion purchase of Aetna Inc. — is offering up more details about the "revolutionary" new health care model it plans to create after the companies officially combine, AIS Health reported.

The Dept. of Justice approved the CVS-Aetna deal in mid-October, contingent upon Aetna selling its Medicare Part D Prescription Drug Plan (PDP) business to WellCare Health Plans, Inc. In addition, 23 out of the 28 states that must approve the transaction have now done so, and CVS is "well down the line" with the remaining five states, CEO Larry Merlo said on the company's third-quarter earnings call. He said CVS now expects to close the deal before Thanksgiving.

Read More

Topics: Industry Trends, Payer, Provider

Radar On Market Access: New Opioid Law Has Implications for MA, Medicaid Plans

Posted by Lauren Flynn Kelly on Nov 8, 2018

One year after the Trump administration declared the opioid crisis a public health emergency, the president signed The SUPPORT for Patients and Communities Act (H.R. 6), a bipartisan legislative package containing myriad provisions aimed at addressing the opioid epidemic. One of the main objectives of the law is to expand access to substance use disorder (SUD) treatment in Medicaid, AIS Health reported.

The new law contains certain flexibilities related to the IMD exclusion, which refers to a longstanding exception that prevented state Medicaid programs from using federal funds to cover care for patients in mental health and SUD residential treatment facilities with more than 16 beds. The primary change is that Section 5052 amends federal Medicaid law by giving state programs the option to cover care in certain IMDs, which may be otherwise not reimbursable for federal funds, for Medicaid beneficiaries aged 21 to 64 with an SUD for fiscal years 2019 to 2023. Through a state plan amendment, states may receive federal reimbursement for up to 30 total days of care in an IMD during a 12-month period for eligible individuals.

Read More

Topics: Industry Trends, Payer, Provider

Radar On Market Access: PhRMA, Feds Spar Over Where To Place Drug Pricing Details

Posted by Judy Packer Tursman on Nov 6, 2018

The 15th of October turned into a day of dueling proposals on the best way for pharmaceutical manufacturers to provide consumers with more information on medication prices. America’s Health Insurance Plans (AHIP) tells AIS Health that it sees merit in the federal government’s approach, while the pharma industry’s plan falls short.

It began with a pre-emptive strike in the morning when the Pharmaceutical Research and Manufacturers Association of America (PhRMA), stressing its commitment to price transparency, issued a press release.

Read More

Topics: Industry Trends, Specialty, Provider

Perspectives on CVS Bid to Lower Drug Launch Prices

Posted by Leslie Small on Nov 1, 2018

In an effort to pressure drug manufacturers to temper their launch prices for new drugs, CVS Health Corp. is rolling out a program in which drugs that have a price exceeding a certain cost-effectiveness threshold will be excluded from coverage, AIS Health reported.

CVS will let clients refuse to cover drugs that have a price tag of more than $100,000 per quality-adjusted life year (QALY), provided they are not designated as "breakthrough" therapies by the FDA.

Read More

Topics: Payer, Specialty, Industry Trends, Data & Analytics, Provider

Radar On Market Access: Express Scripts Exec Urges Smarter Treatment of HIV

Posted by Leslie Small on Nov 1, 2018

At the annual Medicaid Health Plans of America conference, Express Scripts Holding Co. Senior Vice President and Chief Medical Officer Steve Miller, M.D., had a simple message for health plan leaders: "You have to think long term if you're going to have better outcomes," AIS Health reported.

One area in which Medicaid is not heeding that call, Miller said, is how it approaches treating and preventing HIV.

Read More

Topics: Industry Trends, Payer, Specialty, Provider