Drug Benefits

New Sickle Cell Medications Offer Both Opportunities and Challenges

January 2, 2020

The first targeted therapy to treat pain crises in people with sickle cell disease presents a “welcome” new option that payers likely will embrace, a PBM head tells AIS Health. While the drug’s manufacturer cites “positive” early discussions with payers on it, some experts note the lifetime treatment — via a monthly intravenous infusion — is costly: around $100,000 annually.

By Judy Packer-Tursman

The first targeted therapy to treat pain crises in people with sickle cell disease presents a “welcome” new option that payers likely will embrace, a PBM head tells AIS Health. While the drug’s manufacturer cites “positive” early discussions with payers on it, some experts note the lifetime treatment — via a monthly intravenous infusion — is costly: around $100,000 annually.

On Nov. 15, the FDA approved Novartis’ Adakveo (crizanlizumab-tmca), a treatment to fight the underlying cause and reduce the frequency of vaso-occlusive crisis, described as a common and painful complication of sickle cell disease. It is approved for patients ages 16 and older with the genetic blood disorder.

Hydroxyurea, a drug approved by the FDA in 1998, is now generic, costs about $1,000 a year, and is approved for children, the New York Times reported on Dec. 7. The two newcomers are Adakveo and Global Blood Therapeutics’ Oxbryta (voxelotor), a daily pill granted accelerated approval by the FDA 10 days after Adakveo’s approval. This led one expert to tell the news outlet that insurers likely will want to begin with hydroxyurea as the front-line therapy.

Yet Mesfin Tegenu, R.Ph., president of PerformRx, LLC, says that “options for patients with sickle cell disease have been very limited up to this point, so the approval of Adakveo is a welcome addition in the treatment of this debilitating disease.”

Eric Althoff, a Novartis spokesperson, says the company anticipates that health plans will see a value proposition with Adakveo. “Early discussions with payers are positive,” Althoff says. “In fact, a number of payers have already added Adakveo to medical policy including state Medicaid [programs].” Florida and Alabama’s Medicaid programs have agreed to cover Adakveo, Reuters reported on Dec. 20.

Express Scripts, Prime Therapeutics Team Up to Boost Negotiating Clout

December 30, 2019

Major PBM Express Scripts is teaming up with Prime Therapeutics, a PBM owned by 18 Blue Cross and Blue Shield plans, in a deal that one analyst says should silence concerns that Express Scripts might lose health plan customers after being acquired by Cigna Corp.

Under the three-year agreement, Express Scripts “will provide services to Prime related to retail pharmacy network and pharmaceutical manufacturer contracts,” the companies said in a Dec. 19 press release. That means Express Scripts will now negotiate with pharmaceutical manufacturers on behalf of Prime’s 28 million members for drugs covered on the pharmacy benefit, in addition to its own 75 million customers.

By Leslie Small

Major PBM Express Scripts is teaming up with Prime Therapeutics, a PBM owned by 18 Blue Cross and Blue Shield plans, in a deal that one analyst says should silence concerns that Express Scripts might lose health plan customers after being acquired by Cigna Corp.

Under the three-year agreement, Express Scripts “will provide services to Prime related to retail pharmacy network and pharmaceutical manufacturer contracts,” the companies said in a Dec. 19 press release. That means Express Scripts will now negotiate with pharmaceutical manufacturers on behalf of Prime’s 28 million members for drugs covered on the pharmacy benefit, in addition to its own 75 million customers.

That arrangement will let Prime “essentially add to and tap into the purchasing power/scale of Express, ultimately allowing for greater rebates from manufacturers,” Citi Research analyst Ralph Giacobbe wrote in a Dec. 20 note to investors. The collaboration, he said, “represents a transparent…pass-through model as rebates are fully passed on to Prime,” while Prime can also tap into Express Scripts’ retail network, contracting with Cigna and collecting a fee for its services.

However, each company will continue to separately manage “certain relationships on the medical benefit” and value-based contracting, the press release said. The firms’ “other relationships with members, caregivers and key stakeholders” will also remain independent.

“While there are some financial benefits, we view this as a significant favorable development for Cigna and most important for sentiment as [Cigna’s] ability to retain health plan clients has certainly come into question following its combination with [Express Scripts], despite strong retention figures,” Giacobbe advised. “The announcement is clearly an indication of a large sophisticated customer acknowledging the value and benefit of partnering with [Cigna/Express Scripts].”

U.S. Spending on Retail Prescription Drugs Grows Moderately in 2018

December 20, 2019

Total U.S. health care spending increased 4.6% in 2018 to reach $3.6 trillion, according to CMS’s Office of the Actuary. Spending on physician and clinical services went up 4.1% to $725.6 billion, slowing from the 4.7% growth seen in 2017. Meanwhile, spending on retail prescription drugs grew 2.5% in 2018 to total $335.0 billion. In comparison, retail prescription drug spending grew 1.4% in 2017.

by Jinghong Chen

Total U.S. health care spending increased 4.6% in 2018 to reach $3.6 trillion, according to CMS’s Office of the Actuary. Spending on physician and clinical services went up 4.1% to $725.6 billion, slowing from the 4.7% growth seen in 2017. Meanwhile, spending on retail prescription drugs grew 2.5% in 2018 to total $335.0 billion. In comparison, retail prescription drug spending grew 1.4% in 2017. Increased spending on new oncology and autoimmune drugs was partially offset by a decline in drug price growth and increased uptake of generic drugs, the report said. Expenditures on Medicare prescription drugs saw the greatest growth, increasing 5.9% to $107.2 billion in 2018.

NOTE: “Other Health Insurance Programs” may include Children’s Health Insurance Program (Titles XIX and XXI), Department of Defense and Department of Veterans Affairs. Dollar amounts shown are in current dollars. Percent changes are calculated from unrounded data.

SOURCE: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group. Visit https://bit.ly/2RKA4Lh.

Patient-Reported Outcomes Play Key Role in New Multiple Sclerosis Value-Based Contract

December 19, 2019

Under a value-based contracting agreement believed to be the first of its kind, UPMC Health Plan will receive discounts for two Biogen Inc. multiple sclerosis (MS) drugs — Tecfidera (dimethyl fumarate) and Avonex (interferon beta-1a) — based on patient-reported measures of disability progression. The agreement is also based on research with a panel of key MS stakeholders who identified the most meaningful outcomes in relapsing forms of MS.

UPMC’s Center for Value-Based Pharmacy Initiatives led the research and developed the value-based contract.

By Sharon Bender

Under a value-based contracting agreement believed to be the first of its kind, UPMC Health Plan will receive discounts for two Biogen Inc. multiple sclerosis (MS) drugs — Tecfidera (dimethyl fumarate) and Avonex (interferon beta-1a) — based on patient-reported measures of disability progression. The agreement is also based on research with a panel of key MS stakeholders who identified the most meaningful outcomes in relapsing forms of MS.

UPMC’s Center for Value-Based Pharmacy Initiatives led the research and developed the value-based contract.

Previous value-based contracts for MS drugs have connected payment to outcome indicators derived from claims and electronic health record data, says Rochelle Henderson, Ph.D., Express Scripts’ vice president of research and a co-author of the study report.

“This research [gives] a greater level of transparency into the outcome indicators that rank the highest in terms of value for stakeholders,” she says. “The key advantage of patient-reported outcomes is that it gets at information that can be used to evaluate the success of a medication where that information is not available by traditional means.”

Similarly, Henderson says, many outcomes that are important to payers are not available in the electronic medical record. “What we learned is that stakeholders rated ‘worsening physical disability’ and ‘functional impairment’ as the most valuable indicators for providing information about the status of MS.”

Payer interest and participation in outcomes-based contracting with manufacturers continues to grow. “Based on our research and our discussions with stakeholders in health care, there are a number of organizations on the payer side who would like to go in this direction,” says Avalere Health’s John E. Linnehan, practice director of health economics and advanced analytics.

“Payers typically are looking for outcomes-based contracting in conditions with high prevalence, high costs, or both,” Linnehan says, adding that because the MS category includes new entrants and generics, it is a focus of interest for outcomes-based contracts.

Louisiana’s Hepatitis C ‘Netflix’ Model Sees Positive Results

December 18, 2019

Louisiana is off to a fast start on its new payment model aimed at getting costly but curative hepatitis C treatment to patients in Medicaid or incarcerated in state correctional facilities — via a “Netflix”-like, modified subscription service. More Louisiana residents received such treatment in the first 75 days of the new pact than in the entire fiscal year 2019, state officials said Dec. 5, and 2,290 people got treated between the program’s July 15 launch and Nov. 26.

by Judy Packer-Tursman

Louisiana is off to a fast start on its new payment model aimed at getting costly but curative hepatitis C treatment to patients in Medicaid or incarcerated in state correctional facilities — via a “Netflix”-like, modified subscription service. More Louisiana residents received such treatment in the first 75 days of the new pact than in the entire fiscal year 2019, state officials said Dec. 5, and 2,290 people got treated between the program’s July 15 launch and Nov. 26.

It’s all part of a five-year agreement worked out by the Louisiana Dept. of Health with Asegua Therapeutics, a subsidiary of Gilead Sciences, Inc., for an unrestricted amount of Asegua’s direct-acting antiviral medication, the authorized generic of Epclusa (sofosbuvir/velpatasvir), to treat patients in the designated populations.

“The payment model allows a payer — in this case, a state payer — to better manage its costs while maximizing the number of patients who can receive treatment. This is an underlying goal of managed care pharmacy practice,” Academy of Managed Care Pharmacy CEO Susan A. Cantrell, R.Ph., said in a statement to AIS Health.

Louisiana state health officials say they’re encouraged by the new program’s early treatment numbers, but this is a first step: the overarching goal is to eliminate hepatitis C statewide in Louisiana by 2024 among all residents.

To bolster its efforts toward statewide eradication of hepatitis C, the department launched a public awareness campaign the first week of December. Then on Dec. 10, agency officials announced a new collaboration with Walmart Inc., launching a pilot program of free hepatitis screenings in 10 Walmart stores until Feb. 1, 2020.

Highmark Reports Positive Results on OBC with AstraZeneca

December 5, 2019

Highmark recently said its outcomes-based contract (OBC) with AstraZeneca showed positive results for its commercial members with asthma and chronic obstructive pulmonary disease (COPD) taking Symbicort — to the point where the drug manufacturer didn’t have to pay back a rebate to the insurer.

Under Highmark’s year-long agreement with AstraZeneca, announced in April 2018, more than half of its commercial members taking Symbicort (budesonide and formoterol fumarate dihydrate) who had a primary diagnosis of asthma or COPD experienced stabilized or improved symptoms, the insurer says.

By Judy Packer-Tursman

Highmark recently said its outcomes-based contract (OBC) with AstraZeneca showed positive results for its commercial members with asthma and chronic obstructive pulmonary disease (COPD) taking Symbicort — to the point where the drug manufacturer didn’t have to pay back a rebate to the insurer.

Under Highmark’s year-long agreement with AstraZeneca, announced in April 2018, more than half of its commercial members taking Symbicort (budesonide and formoterol fumarate dihydrate) who had a primary diagnosis of asthma or COPD experienced stabilized or improved symptoms, the insurer says.

Overall, Highmark’s involvement in OBCs is growing rapidly. The insurer “will have 15 [such] contracts in place by January 2020 and we’re looking to do more,” says Kayse Reitmeyer, Pharm.D., Highmark’s manager of pharmaceutical manufacturer relations and rebate administration.

She explains that Highmark “has moved on to different types of contract designs” for OBCs, including medical outcomes-based agreements, where the manufacturer offers a design centered around a drug’s clinical trial results; “persistency” or medication adherence-based agreements to track whether members are continuing therapy; and total cost-of-care contracts that track both pharmacy and medical spend.

To date, Highmark has publicly disclosed two OBCs: a total cost-of-care design on Jardiance (empagliflozin), marketed by Boehringer Ingelheim Pharmaceuticals, Inc., and Eli Lilly and Co. for patients with diabetes; and a persistency and adherence-based design on Takeda Pharmaceuticals America, Inc.’s Entyvio (vedolizumab) for patients with irritable bowel syndrome, ulcerative colitis or Crohn’s disease, Reitmeyer says. Highmark expects to disclose two to three more OBCs in the next few months “and share some Jardiance results soon,” she says.

Looking ahead, Highmark “will have a total cost-of-care contract in respiratory, tracking per member per month [PMPM] or per member per year [PMPY], looking at all medical and pharmacy costs in a certain drug class,” Reitmeyer says.

As for Symbicort, Highmark is in discussions with AstraZeneca about evolving that contract, she adds.