Drug Benefits

Datapoint: Amerigroup Georgia Adds New Benefits to Address SDOH

June 26, 2019

Amerigroup Community Care, Anthem Inc.’s Medicaid unit in Georgia, announced June 20 that it is adding new benefits to support enrolled families with children, and address social determinants of health that can make Medicaid members more expensive to insure. The no-cost benefits include tutoring programs and SAT preparation for older children, and free baby food for infants following their 6-month check-up. Amerigroup currently serves 375,471 Medicaid and CHIP members in Georgia, 26.2% of the state’s managed Medicaid lives.

Amerigroup Community Care, Anthem Inc.’s Medicaid unit in Georgia, announced June 20 that it is adding new benefits to support enrolled families with children, and address social determinants of health that can make Medicaid members more expensive to insure. The no-cost benefits include tutoring programs and SAT preparation for older children, and free baby food for infants following their 6-month check-up. Amerigroup currently serves 375,471 Medicaid and CHIP members in Georgia, 26.2% of the state’s managed Medicaid lives.

Source: AIS’s Directory of Health Plans

Datapoint: ICER Rules That Mayzent and Spravato Are Not Cost Effective

June 25, 2019

The Institute for Clinical and Economic Review (ICER) last week ruled two highly anticipated (and potential blockbuster) drugs, Novartis’ Mayzent and Janssen’s Spravato, are not cost effective. The nonprofit industry watchdog said Spravato, which holds covered status for just 3% of all insured lives, should lower its list price by 25% to 52%. In Mayzent’s case, ICER said payers should grant preferred formulary status to a generic variant of Novartis’ Gilenya instead, once it hits the market. For the treatment of Multiple Sclerosis, Mayzent currently holds preferred status for 6% of covered lives, with step therapy and/or prior authorization.

The Institute for Clinical and Economic Review (ICER) last week ruled two highly anticipated (and potential blockbuster) drugs, Novartis’ Mayzent and Janssen’s Spravato, are not cost effective. The nonprofit industry watchdog said Spravato, which holds covered status for just 3% of all insured lives, should lower its list price by 25% to 52%. In Mayzent’s case, ICER said payers should grant preferred formulary status to a generic variant of Novartis’ Gilenya instead, once it hits the market. For the treatment of Multiple Sclerosis, Mayzent currently holds preferred status for 6% of covered lives, with step therapy and/or prior authorization.

SOURCE: MMIT Analytics, as of 6/24/19

Datapoint: FDA Approves First U.S. Herceptin Biosimilar

June 19, 2019

The FDA last week approved Amgen Inc.’s Kanjinto, a biosimilar to Roche’s Herceptin, for both of Herceptin’s oncology indications. For the treatment of breast cancer and gastric cancer, Herceptin holds preferred status for 10% of covered lives under the pharmacy benefit. It is not covered for 17% of lives.

The FDA last week approved Amgen Inc.’s Kanjinto, a biosimilar to Roche’s Herceptin, for both of Herceptin’s oncology indications. For the treatment of breast cancer and gastric cancer, Herceptin holds preferred status for 10% of covered lives under the pharmacy benefit. It is not covered for 17% of lives.

SOURCE: MMIT Analytics, as of 6/17/19

Magellan Rx Initiates Oncology Biosimilars Program

June 19, 2019

Magellan Rx Management, the PBM division of Magellan Health, Inc., on June 4 announced its launch of an oncology biosimilars program, preparing its health plan customers for the expected market entry of biosimilars for three cancer-fighting drugs — Herceptin, Rituxan and Avastin — later this year.

“Oncology is by far the largest therapeutic area for drug spend on the medical benefit, and it is even higher in Medicare,” Steve Cutts, senior vice president and general manager for Magellan Rx’s specialty drug unit, tells AIS Health. Thus, he says, the PBM will be focusing the oncology biosimilars program “on all lines of business for our clients.”

By Judy Packer-Tursman

Magellan Rx Management, the PBM division of Magellan Health, Inc., on June 4 announced its launch of an oncology biosimilars program, preparing its health plan customers for the expected market entry of biosimilars for three cancer-fighting drugs — Herceptin, Rituxan and Avastin — later this year.

“Oncology is by far the largest therapeutic area for drug spend on the medical benefit, and it is even higher in Medicare,” Steve Cutts, senior vice president and general manager for Magellan Rx’s specialty drug unit, tells AIS Health. Thus, he says, the PBM will be focusing the oncology biosimilars program “on all lines of business for our clients.”

The three oncology brand drugs together account for $9 billion in U.S. drug sales, and almost $50 million in annual drug spend per 1 million covered commercial lives, Magellan Rx says. The PBM anticipates savings of $5 million to $8 million per 1 million covered lives via its new program but sees “potential for even greater savings based on [its] past successes with biosimilars.”

Under a multi-pronged program, Magellan Rx aims to develop clinical protocols while educating and communicating with network oncologists; incorporate biosimilars into key utilization management programs, such as medical prior authorization and provider reimbursement/fee schedule management; and work continuously with its oncology advisory board.

Cutts notes that Herceptin, Rituxan and Avastin “all have FDA approved biosimilars which are due to be launched and available on the market in 2019, with some speculated to be available as soon as this month.”

Payers Are Wary as First NASH Drugs May Hit U.S. Market Soon

June 17, 2019

Doctors trying to treat patients with nonalcoholic steatohepatitis (NASH) — a serious type of nonalcoholic fatty liver disease (NAFLD) that, if left untreated, may progress to cardiovascular disease, cirrhosis, cancer and possibly the need for a liver transplant — soon may have new options in their arsenal beyond promoting exercise and diet. The first-ever NASH drugs are expected to hit the U.S. market as early as 2020 to help address this increasingly prevalent, complex disease spawned largely by the obesity epidemic and surge of type 2 diabetes in the U.S.

By Judy Packer-Tursman

Doctors trying to treat patients with nonalcoholic steatohepatitis (NASH) — a serious type of nonalcoholic fatty liver disease (NAFLD) that, if left untreated, may progress to cardiovascular disease, cirrhosis, cancer and possibly the need for a liver transplant — soon may have new options in their arsenal beyond promoting exercise and diet. The first-ever NASH drugs are expected to hit the U.S. market as early as 2020 to help address this increasingly prevalent, complex disease spawned largely by the obesity epidemic and surge of type 2 diabetes in the U.S.

Dieterich says the entry of first-ever NASH medications will “definitely” offer significant benefit to patients. “There’s no question [the drugs will help] — in combination with diet and exercise,” says Douglas Dieterich, M.D., director of the Institute for Liver Medicine at Mount Sinai Health System. “It will have to be the whole package.”

Multiple drugs are in phase 3 clinical trials for NASH. A front-runner is Intercept Pharmaceuticals, Inc.’s drug, Ocaliva (obeticholic acid), already on the market to treat another liver condition. But the FDA isn’t expected to approve Intercept’s drug for NASH until the second quarter of 2020, Dieterich notes.

Dieterich says he expects NASH medications will “undoubtedly” be marketed as specialty drugs that will be “strictly controlled” by PBMs and insurance companies. He expects such drugs to become available only to the sickest patients, possibly only after a diagnostic liver biopsy is performed.

From a plan perspective, Yusuf Rashid, R.Ph., vice president of pharmacy and vendor relationship management at Community Health Plan of Washington, says NASH “has similarities to other recent new breakthrough therapies where the outcome we are trying to avoid is costly and potentially fatal but not all patients…will even progress to fibrosis. The reason why NASH is more significant is the sheer number of patients that may qualify for treatment.”

Formulary Search Rebrand Enhances the Big Picture, Adds Medical Benefit View

June 13, 2019

MMIT on July 1 will rebrand Formulary Search as Coverage Search, a move that reflects the full portfolio of our capabilities, as well as the complex variances between pharmacy and medical benefit coverage, and the industry’s shift toward increasingly restrictive coverage policies. You will be able to add a comprehensive new package on medical benefit coverage and policies, creating a more complete picture of the entire market access landscape.

MMIT on July 1 will rebrand Formulary Search as Coverage Search, a move that reflects the full portfolio of our capabilities, as well as the complex variances between pharmacy and medical benefit coverage, and the industry’s shift toward increasingly restrictive coverage policies. You will be able to add a comprehensive new package on medical benefit coverage and policies, creating a more complete picture of the entire market access landscape.

New Medical Benefit View: “Previously, clients would think Formulary Search means formularies, so it means pharmacy benefit products only. But now we can help brands create a more complex strategy so that they can speak to coverage across benefit types,” says Greg Lee, a product manager at MMIT. “This is a really important thing for our clients, because the way insurance companies are covering products — particularly physician-injected drugs, IV drugs and hospital-administered drugs — is changing, and insurance companies are getting more complex in how they create utilization management techniques on both benefits.”

App Changes Tackle Uncertainty: Some drugs, particularly oncology products and specialty biologics, can be covered under both the medical and pharmacy benefit, and Lee says this creates a level of nuance health care providers can struggle with. “If they do buy-and-bill, will it be reimbursed? Or if it’s a drug that the patient can potentially obtain through a specialty pharmacy, is that the better approach?”

Coverage Search’s new capabilities can display benefit information that can tackle this uncertainty. “It allows companies to be more complex and more nuanced in their discussion of coverage for these brands that are being covered in different ways,” Lee says.

Solutions That Fit Your Needs: With the introduction of Coverage Search, our Client Success Leads (CSLs) can provide you with a full picture of the dynamic between the pharmacy benefit and the medical benefit, and create configured solutions that best fit a brand’s promotional needs. Lee says the custom status can highlight the most important restriction(s) information for any product. “If you’re talking with an oncologist, the strategy is to highlight the fact that the insurance company is covering the product to National Comprehensive Cancer Network (NCCN) guidelines, or to the product’s label,” Lee gives as an example. “The CSL will work to understand what the product’s label is, what the guidelines are, how that compares to the restrictions that MMIT is assessing, and then create a custom status that allows the client to promote on access that is covered to label, or covered to NCCN recommendations, and that really allows a promotional strategy that’s very specific to that product as well as the indication.”

The new version of the application will available for download from the Apple App store and the Google Play store July 1.