People on the Move

May 24, 2019

Current Market Access to Chronic Obstructive Pulmonary Disease (COPD) Medications

May 24, 2019

All COPD medications are covered under the pharmacy benefit with some limitations, most frequently prior authorizations and quantity limits. Four medications — Brovana, Lonhala Magnair Starter, Perforomist and Yupelri — are covered under the medical benefit. For most of the drugs on the market, more than half of covered lives are under the preferred tier/preferred with prior authorization or step therapy and covered tier/covered with PA/ST. Payer pharmacy benefit formularies require ST for 16% of the covered lives and PA for 26% of the lives.

by Jinghong Chen

All COPD medications are covered under the pharmacy benefit with some limitations, most frequently prior authorizations and quantity limits. Four medications — Brovana, Lonhala Magnair Starter, Perforomist and Yupelri — are covered under the medical benefit. For most of the drugs on the market, more than half of covered lives are under the preferred tier/preferred with prior authorization or step therapy and covered tier/covered with PA/ST. Payer pharmacy benefit formularies require ST for 16% of the covered lives and PA for 26% of the lives. The graphics below show how COPD medications are covered among commercial health plans, health exchange programs and Medicare and Medicaid programs, and their utilization management restrictions.

NOTE: Under the pharmacy benefit, the numbers of total covered lives under commercial, health exchange, Medicare and Medicaid formularies are 108.9 million, 10.2 million, 33.2 million and 62.0 million, respectively. Under the medical benefit, the numbers of total covered lives under commercial, health exchange, Medicare and Medicaid formularies are 184.9 million, 10.2 million, 44.5 million and 62.0 million, respectively.

SOURCE: Managed Markets Insight & Technology, LLC database as of May 2019.

Datapoint: Louisiana Seeks to Expand Medicaid Access to More Children

May 23, 2019

The Louisiana House of Representatives this week unanimously passed a bill that will expand Medicaid coverage, including home- and community-based services, to children with disabilities whose parents’ incomes disqualifies them from coverage. Louisiana’s managed Medicaid program currently serves 1,533,075 lives, while an additional 149,046 remain covered through fee-for-service Medicaid. About 36% of the state’s population is enrolled in Medicaid.

The Louisiana House of Representatives this week unanimously passed a bill that will expand Medicaid coverage, including home- and community-based services, to children with disabilities whose parents’ incomes disqualifies them from coverage. Louisiana’s managed Medicaid program currently serves 1,533,075 lives, while an additional 149,046 remain covered through fee-for-service Medicaid. About 36% of the state’s population is enrolled in Medicaid.

Source: AIS’s Directory of Health Plans

Increasing Focus on Dual Integration May be Key to Possible Humana-Centene Combination

May 23, 2019

As Centene Corp. and WellCare Health Plans, Inc. prepare to create a “premier” government-sponsored health insurance entity, news emerged earlier this month that certain Centene shareholders may be seeking to block the deal in favor of selling Centene to a large company such as Humana Inc. Although Humana declined to comment on reports of a possible friendly takeover, industry experts say acquiring a major Medicaid provider would make sense for the insurer given increasing integration of Medicare and Medicaid.

By Lauren Flynn Kelly

As Centene Corp. and WellCare Health Plans, Inc. prepare to create a “premier” government-sponsored health insurance entity, news emerged earlier this month that certain Centene shareholders may be seeking to block the deal in favor of selling Centene to a large company such as Humana Inc. Although Humana declined to comment on reports of a possible friendly takeover, industry experts say acquiring a major Medicaid provider would make sense for the insurer given increasing integration of Medicare and Medicaid.

Centene in late March said it planned to buy WellCare for approximately $17.3 billion. Reuters on May 6 reported that hedge funds Corvex Management LP and Sachem Head Capital Management LP are exploring challenging that acquisition; a report from StreetInsider followed that indicated Humana’s interest in pursuing a deal if Centene walked away from WellCare. But Centene spokesperson Marcela Hawn affirmed the company’s commitment to the transaction in an email to AIS Health.

The reported desire of Centene shareholders to have an “arranged marriage” with Humana is not necessarily surprising, given that Centene is the biggest player in Medicaid with a desire to grow its MA business, remarks Alex Shekhdar, founder of Sycamore Creek Healthcare Advisors. Such a deal would have less market overlap than Centene-WellCare and therefore involve fewer divestitures and an easier regulatory approval process, he suggests.

“This is all about duals, all about the interface of Medicare and Medicaid and the potential growth of MLTSS [managed long-term services and supports],” he says of a possible Humana-Centene combination.

Are Surprises Ahead For Legislation To Curb Surprise Medical Bills?

May 22, 2019

Surprise medical bills — those unexpected and often pricey bills patients face when they get care from a doctor or hospital that isn’t in their insurance network — are the health care problem du jour in Washington, with congressional lawmakers from both sides of the aisle and the White House calling for action.

These policymakers agree on the need to take patients out of the middle of the fight over charges, but crafting a legislative solution will not be easy.

Surprise medical bills — those unexpected and often pricey bills patients face when they get care from a doctor or hospital that isn’t in their insurance network — are the health care problem du jour in Washington, with congressional lawmakers from both sides of the aisle and the White House calling for action.

These policymakers agree on the need to take patients out of the middle of the fight over charges, but crafting a legislative solution will not be easy.

A hearing of the House Ways and Means health subcommittee Tuesday, for example, quickly devolved into finger-pointing as providers’ and insurers’ testimony showed how much they don’t see eye to eye.

“I’m disappointed that all participants that are going to be here from critical sectors of our economy could not come to find a way to work together to protect patients from these huge surprise bills,” Rep. Devin Nunes (R-Calif.), the ranking Republican on the subcommittee, said in his opening statement….

Read the full Kaiser Health News article