Radar on Drug Benefits

Low-Cost Enhanced PDP Offerings See Growth in 2020

October 16, 2019

When it comes to Medicare Part D stand-alone Prescription Drug Plans (PDPs) in 2020, experts say the most notable trend is the rising prevalence of lower-cost enhanced plan offerings.

According to CMS’s recently released landscape files, there will be a total of 1,433 PDP plans in 2020, up from 1,369 in 2019.

That increase is “mainly due to additional enhanced, low-premium plans being offered this year, both through existing carriers offering new plans, and then there’s also a new entrant to the national PDP market,” says Shelly Brandel, a principal and consulting actuary in the Milwaukee office of Milliman, Inc.

By Leslie Small

When it comes to Medicare Part D stand-alone Prescription Drug Plans (PDPs) in 2020, experts say the most notable trend is the rising prevalence of lower-cost enhanced plan offerings.

According to CMS’s recently released landscape files, there will be a total of 1,433 PDP plans in 2020, up from 1,369 in 2019.

That increase is “mainly due to additional enhanced, low-premium plans being offered this year, both through existing carriers offering new plans, and then there’s also a new entrant to the national PDP market,” says Shelly Brandel, a principal and consulting actuary in the Milwaukee office of Milliman, Inc.

The new carrier, Clear Spring Health, will offer PDPs for the first time in 2020 in 41 states and Washington, D.C. Brandel notes that Clear Spring’s Premier Rx plans, an enhanced offering, have an average premium of around $15.

Also worth noting is that Humana Inc. created a new offering called the Humana Walmart Value Rx Plan. The premium for that plan is $13.20 across all states.

WellCare Health Plans, Inc., meanwhile, is offering the new WellCare Wellness Rx plan, an enhanced plan that has an average premium of about $14, according to Brandel.

In general, Brandel says, “the enhanced plans with low premiums have been an area of growth in the PDP market.”

A regulatory change in 2018 — which said plan sponsors no longer have to demonstrate that their enhanced PDPs offered in the same region are “meaningfully different” regarding enrollee out-of-pocket costs — likely made it easier for insurers to offer low-premium enhanced plans, Brandel says. However, “the main reason more of these plans are being offered is because they are popular with members,” she adds.

Across all PDP offerings, the projected average monthly basic Part D premium in 2020 will be $30 — the lowest it’s been since 2013, according to CMS.

Despite Approval of New Parkinson’s Drugs, Plans Still Prefer Generics

October 2, 2019

Although three new drugs for Parkinson’s disease have been approved over the last year, plans generally are sticking with the drugs they’ve included on formularies for several years, most of which are generic, experts say.

That may change in the long term as new gene therapies that currently are in development are approved and come online. But none of those potential new treatments are close to market right now, says Mesfin Tegenu, R.Ph., president of PerformRx.

By Jane Anderson

Although three new drugs for Parkinson’s disease have been approved over the last year, plans generally are sticking with the drugs they’ve included on formularies for several years, most of which are generic, experts say.

That may change in the long term as new gene therapies that currently are in development are approved and come online. But none of those potential new treatments are close to market right now, says Mesfin Tegenu, R.Ph., president of PerformRx.

“Many commonly used therapies for Parkinson’s disease — carbidopa-levodopa, MAO-Bs, dopamine agonists — have available generics, which on most plans would be considered formulary options, or one generic product within each class would be selected as formulary,” Tegenu tells AIS Health.

The FDA in August approved Kyowa Kirin, Inc.’s Nourianz (istradefylline) tablets as an add-on treatment to levodopa/carbidopa in adult patients with Parkinson’s disease experiencing motor fluctuations. In February, the FDA approved Osmotica Pharmaceutical US LLC’s Osmolex ER (amantadine) for the treatment of Parkinson’s disease. And in late December, the FDA approved Accorda Therapeutics’ Inbrija (levodopa inhalation powder) for intermittent treatment of off episodes in people with Parkinson’s disease taking carbidopa/levodopa.

Still, plans are stocking their formularies with less expensive generic medications. Parkinson’s disease treatment generally progresses through drugs that have a moderate effect but fewer side effects to drugs that are more effective, but have more significant side effects, Tegenu says.

“Choice of which pharmacotherapy to use initially is individualized based on the characteristics of the patient, the disease and the drugs,” he says. “There is no single preferred therapy, and trade-offs are common.”

Plans aren’t expected to cover Inbrija, Tegenu says. “Members would be able to request an exception through the prior authorization process for these products,” he adds. For Osmolex ER, plans generally require failure on trials of immediate-release amantadine.

Does New Medicare Plan Finder Make Part D Plans Tougher to Parse?

September 30, 2019

Some Medicare experts are expressing concern and frustration about changes to the Medicare Plan Finder that may make it more difficult for beneficiaries to find the best Part D plan for their unique circumstances.

For example, the version of the new plan finder that CMS debuted does not include the ability to sort Part D plans based on a beneficiary’s total out-of-pocket drug costs (including plan premium) for the rest of the year, says Ann Kayrish, who is the National Council on Aging’s senior program manager for Medicare.

By Leslie Small

Some Medicare experts are expressing concern and frustration about changes to the Medicare Plan Finder that may make it more difficult for beneficiaries to find the best Part D plan for their unique circumstances.

For example, the version of the new plan finder that CMS debuted does not include the ability to sort Part D plans based on a beneficiary’s total out-of-pocket drug costs (including plan premium) for the rest of the year, says Ann Kayrish, who is the National Council on Aging’s senior program manager for Medicare.

The good news, she says, is that CMS notified stakeholders that the total-cost calculator feature will be in place in time for the annual election period (AEP) that begins Oct. 15 — which CMS confirmed to AIS Health.

However, Kayrish says it’s still problematic that the total-cost calculator isn’t yet available to test before the hectic AEP begins. “We don’t want open enrollment to be like a beta test for the new plan finder,” she says.

Elizabeth Gavino, founder of insurance consulting firm Lewin & Gavino and an independent broker and a general agent for Medicare plans located in the New York City area, also has qualms with the way the new plan finder is designed.

The old plan finder allowed brokers to quickly scan multiple Part D plans and see whether all of the person’s medications are on their formularies. Now, that information is only available by clicking on a “plan details” button for each individual Part D plan, she explains.

“I could do a review for a client in 10 minutes” with the old system, Gavino says. “The way it is now, this is going to be a nightmare.”

Health Plans Are Hesitant to Add New Narcolepsy Drugs to Formularies

September 18, 2019

Two newly approved narcolepsy medications offer novel, possibly more effective options to people for whom older medications aren’t working well, but most health plans are requiring patients and providers to try generic alternatives first.

The FDA approved Jazz Pharmaceuticals’ Sunosi (solriamfetol) for adults with narcolepsy or obstructive sleep apnea in March and Harmony Biosciences, LLC’s Wakix (pitolisant) in August. Sunosi was launched in July, and Wakix is expected to be launched later this year.

By Jane Anderson

Two newly approved narcolepsy medications offer novel, possibly more effective options to people for whom older medications aren’t working well, but most health plans are requiring patients and providers to try generic alternatives first.

The FDA approved Jazz Pharmaceuticals’ Sunosi (solriamfetol) for adults with narcolepsy or obstructive sleep apnea in March and Harmony Biosciences, LLC’s Wakix (pitolisant) in August. Sunosi was launched in July, and Wakix is expected to be launched later this year.

Some researchers say Sunosi and Wakix may have advantages over older treatments. Still, plans have been reluctant so far to add Sunosi to their preferred drug lists, and they seem likely to take the same cautious approach with Wakix.

First-line treatment for narcolepsy generally involves stimulant medications such as methylphenidate, amphetamines or modafinil/armodafinil, says Mesfin Tegenu, R.Ph., president of PerformRx. “Efficacy of the agents rarely exceeds around 70% to 80% of the normal ability to stay awake,” Tegenu tells AIS Health.

Some stimulants, including modafinil and some forms of methylphenidates and amphetamines, are available in generic form, Tegenu says. “Many plans may require trial(s) of an available generic product prior to payment of a brand-only formulation, or trial of less costly alternatives to higher-priced generic items if there’s a significant price difference,” he says.

It’s not clear whether either Sunosi or Wakix provide substantially better outcomes than the therapies currently in use, says April Kunze, Pharm.D., senior director, clinical formulary development and trend management strategy at Prime Therapeutics LLC.

Tegenu says that both Sunosi and Wakix are non-formulary products for now for PerformRx, since it’s not possible to know whether they’re equally or more effective than older treatments. They will be “handled the same as all newly available drugs: considered non-formulary until enough clinical data is made available to add them to the covered medications class of drugs.”

New Solutions to Finance High-Cost Treatments May Raise New Questions

September 16, 2019

With concerns mounting about how health plan sponsors will pay for breakthrough treatments with ultra-high price tags, some major insurers are offering up new solutions aimed at easing that burden.

Cigna Corp. “appears at the forefront” of initiatives to cope with super-high-cost drugs, as Citi analyst Ralph Giacobbe puts it, given that the firm recently introduced a new solution that would help clients pay for and manage two gene therapies: Luxturna and Zolgensma.

By Leslie Small

With concerns mounting about how health plan sponsors will pay for breakthrough treatments with ultra-high price tags, some major insurers are offering up new solutions aimed at easing that burden.

Cigna Corp. “appears at the forefront” of initiatives to cope with super-high-cost drugs, as Citi analyst Ralph Giacobbe puts it, given that the firm recently introduced a new solution that would help clients pay for and manage two gene therapies: Luxturna and Zolgensma.

Members whose plan sponsors pay a per-member per-month fee for Cigna’s new solution — called Embarc Benefit Protection — will pay nothing out of pocket for Zolgensma or Luxturna if they meet the clinical qualifications to be treated with one of those therapies.

“Employers are looking for solutions like that from their health plan partners and the PBMs,” says Steve Wojcik, vice president of public policy for the National Business Group on Health. However, while offerings like Cigna’s could help employers “smooth out the spikes in expenses,” businesses remain concerned about the overall costs of breakthrough therapies in the pipeline, he notes.

Besides Cigna, other major names in the insurance sector, such as CVS Health Corp.’s Aetna and Anthem, Inc., are working on their own solutions to help cope with high-cost therapies, including annuity-style payment arrangements and value-based contracts.

David Dross, managed pharmacy practice leader at the consulting firm Mercer, says some large, self-insured employers that are concerned about ultra-costly treatments are rethinking their decision to forgo stop-loss coverage.

However, issues can arise if clinical and financial management of a high-cost drug are done separately, he adds. In other words, a plan sponsor may determine that a member qualifies for a high-cost drug, but the stop-loss carrier that’s taking on the financial responsibility may not agree.