Member: RADAR on Drug Benefits

CMS Backs Closed Medicaid Formularies…But Are They Legal?

February 13, 2020

As part of long-awaited guidance that CMS issued to states on Jan. 30 outlining how they can test-drive a fixed federal Medicaid budget and more program flexibilities, the Trump administration invited states to try out something else that hasn’t been done before: implement a closed drug formulary for a portion of their Medicaid population.

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Payers Test Ways to Control Rising Cost of Diabetes Drugs

With Chart: Current Market Access to Select Insulin Drugs

February 13, 2020

With the cost of diabetes drugs still growing, PBMs and payers are looking for more innovative strategies to hold down costs. For some, that might include a strategy similar to the one recently unveiled by CVS Health Corp.’s Caremark unit. The plan, called RxZERO, offers a slimmer formulary for the diabetes drug class, but with no out-of-pocket costs for members. CVS says employers or insurers that pick this plan should expect to save about $30 annually per member.

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PBM Integration Helps Drive Solid 2019 Earnings, Execs Say

February 13, 2020

The health care industry’s largest payers continue to make the case that they are gaining — or project to gain — substantial benefits from integrating PBM businesses.

In particular, Cigna Corp. expects its integration of PBM Express Scripts to drive substantial prescription claim growth in the coming year, and Humana Inc. projects cost savings from its recent acquisition of hospice-focused PBM Enclara Pharmacia Inc.

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Cancer, Neurology Drugs Lead 2020 Pharma Pipeline

February 13, 2020

In its quarterly drug pipeline trends report, OptumRx projected that 2020 will see large numbers of drug approvals for oncology drugs and identified 11 drugs with the potential to be blockbusters in the United States.

OptumRx, which is owned by UnitedHealth Group, sorted the drugs likely to be approved this year into 17 treatment categories. Cancer-treating drugs were by far the most prevalent, with 44 likely approvals. Neurology followed with 29.

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News Briefs

February 13, 2020

✦ CMS on Feb. 5 issued a proposed rule that would allow Medicare Part D sponsors to establish a second, “preferred” specialty drug tier with lower cost-sharing than the current specialty tier — after plan sponsors and PBMs indicated that would encourage the use of more preferred, less expensive agents. The proposed rule, which includes an array of changes to the Medicare Advantage and Part D programs for policy years 2021 and 2022, also would require each Part D plan to implement a Beneficiary Real Time Benefit Tool that lets enrollees view plan-provided, patient-specific, real-time formulary and benefit information. Visit https://go.cms.gov/38kOG9w to learn more.

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