Final Flexibility Rule Expands Telehealth Benefits Under Medicare Advantage

April 25, 2019

With the April 5 release of the Calendar Year 2020 Medicare Advantage and Part D Flexibility Final Rule that implements many provisions of the Bipartisan Budget Act of 2018, MA organizations may offer telehealth services on a scale that’s never been allowed before.

Under the final rule, MA plans starting in 2020 will be able to offer as part of the basic benefit package “additional telehealth benefits” beyond what is available to Medicare fee-for-service beneficiaries and to include more telehealth services in their basic benefit bid paid by the capitation rate.

By Lauren Flynn Kelly

With the April 5 release of the Calendar Year 2020 Medicare Advantage and Part D Flexibility Final Rule that implements many provisions of the Bipartisan Budget Act of 2018, MA organizations may offer telehealth services on a scale that’s never been allowed before.

Under the final rule, MA plans starting in 2020 will be able to offer as part of the basic benefit package “additional telehealth benefits” beyond what is available to Medicare fee-for-service beneficiaries and to include more telehealth services in their basic benefit bid paid by the capitation rate.

CMS also finalized a requirement that if an MA plan covers a Part B service as an additional telehealth benefit, it must also provide access to such a service through an in-person visit and not only through “electronic exchange.”

“I think this is going to be a positive impact from a health plan perspective and I think this is something that health plans wanted CMS to implement for a while,” remarks Brian Collender, specialist leader in the health actuarial practice of Deloitte Consulting. For those larger MA plans that already have telehealth relationships set up with national vendors, expanding telehealth is a low cost/low risk opportunity, he says. Smaller health plans, meanwhile, may not have the capabilities to offer telehealth as a benefit right away, but have options when it comes to vendors that specialize in telehealth.

Moreover, “by reclassifying telehealth services as Medicare-covered under Parts A and B, MA plans can offer telehealth without using up precious rebate dollars that fund supplemental benefits,” says Michael Adelberg, a principal with Faegre Baker Daniels Consulting and a former top CMS MA official.

Datapoint: Year-Over-Year Medicaid Enrollment

April 24, 2019

Nationwide enrollment in Medicaid and CHIP shrunk 0.46% to 74.4 million lives from April 2018 to April 2019, according to the latest update to AIS’s Directory of Health Plans. This includes enrollment in both Medicaid fee-for-service and managed care plans.

Nationwide enrollment in Medicaid and CHIP shrunk 0.46% to 74.4 million lives from April 2018 to April 2019, according to the latest update to AIS’s Directory of Health Plans. This includes enrollment in both Medicaid fee-for-service and managed care plans.

Source: AIS’s Directory of Health Plans

Copay Accumulators’ Use Rises; Virginia Passes Law Banning Such Programs

April 24, 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.

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.

By Angela Maas

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.

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.

It also explores the use of a similar kind of program: copay maximizers. Among 51 payer respondents covering 177.9 million lives, payers covering more than 50 million commercial lives have implemented a copay maximizer program. But payers representing 58% of covered lives say they do not have plans to incorporate maximizers within their benefits offerings.

Melinda Haren, a senior consultant at Zitter Insights, notes that accumulators and maximizers are focused on specialty drugs, particularly those products that are adjudicated through the pharmacy benefit.

The savings for payers — and the additional burden on manufacturers — are not insignificant. But drugmakers can do little to limit the use of these programs, at least in the short term, says Haren.

One recent effort may prove to be effective against accumulators: On March 21, Virginia Gov. Ralph Northam (D) signed a law that will go into effect Jan. 1, 2020, which states, in part, “When calculating an enrollee’s overall contribution to any out-of-pocket maximum, deductible, copayment, coinsurance, or other cost-sharing requirement under a health plan, a carrier shall include any amounts paid by the enrollee or paid on behalf of the enrollee by another person.”

This approach to counter accumulators “will likely be effective, at least in the near term,” maintains Jeremy Schafer, Pharm.D., senior vice president of payer access solutions at Precision for Value.

Datapoint: Novartis’ Sandoz Sues United Therapeutics Over Remodulin Access

April 23, 2019

Novartis’ generic unit Sandoz has sued United Therapeutics for what it calls anticompetitive behavior over its copies of United’s Remodulin. Novartis says United placed “artificial restrictions” on cartridges needed for intravenous delivery of the pulmonary arterial hypertension drug. In the pharmacy benefit, Remodulin holds preferred-tier access for 10% of covered lives, and is not covered for 19% of lives.

Novartis’ generic unit Sandoz has sued United Therapeutics for what it calls anticompetitive behavior over its copies of United’s Remodulin. Novartis says United placed “artificial restrictions” on cartridges needed for intravenous delivery of the pulmonary arterial hypertension drug. In the pharmacy benefit, Remodulin holds preferred-tier access for 10% of covered lives, and is not covered for 19% of lives.

SOURCE: MMIT Analytics, as of 4/22/19

2019 Specialty Pharmacy Patient Choice Awards Finalists Announced

April 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.

Rankings for the Patient Choice Awards are based on these organizations’ average Net Promoter Score from quarterly Zitter Insights Specialty Pharmacy Patient Satisfaction Surveys. Finalists for this annual award are selected for achieving the highest patient satisfaction scores in one of two categories: A) PBM/Payer Specialty Pharmacy or B) Non-PBM/Payer Specialty Pharmacy.

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.

Rankings for the Patient Choice Awards are based on these organizations’ average Net Promoter Score from quarterly Zitter Insights Specialty Pharmacy Patient Satisfaction Surveys. Finalists for this annual award are selected for achieving the highest patient satisfaction scores in one of two categories: A) PBM/Payer Specialty Pharmacy or B) Non-PBM/Payer Specialty Pharmacy.

The team at Zitter Insights, which is now a part of MMIT, the industry standard in formulary, policy and restriction data, is proud to announce the following finalists for the 2019 Patient Choice Awards:

Payer/PBM-Based Specialty Pharmacies:
• CVS Specialty
• Humana Specialty Pharmacy
• US Specialty Care

Retail/Independent/Hospital and Health System Specialty Pharmacies:
• BioPlus Specialty Pharmacy
• Credena Health (Providence)
• Onco360 Oncology Pharmacy
• PANTHERx Specialty Pharmacy
• Vanderbilt University Medical Center Specialty Pharmacy

The winner in each category will be announced during the Patient Choice Awards in the fall of 2019. Additional information on the event will be distributed later in the year.

A core element of MMIT’s philosophy is recognizing industry leaders who help to simplify complex healthcare challenges – in this case, specialty pharmacies. In this same vein, the organization will continue to heavily invest in the Specialty Pharmacy Patient Choice Awards and bring awareness to the outstanding performance of the organizations who lead this industry into the future of healthcare.