Radar on Drug Benefits

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.

New Acute Migraine Medications May Not Shake Up Formularies

December 4, 2019

New oral medications for acute migraine — one pending launch and two more that could be approved in the coming months — likely won’t shake up formulary coverage for a condition that’s largely treated by generic triptan medications, pharmacy benefit experts say.

Eli Lilly and Co. on Oct. 11 received FDA approval for its drug Reyvow (lasmiditan), an oral medication that’s the first serotonin (5-HT)1F receptor agonist to be approved for migraine. Meanwhile, Allergan on Nov. 19 said it’s on track for December FDA consideration of ubrogepant, an oral CGRP receptor antagonist for acute migraine. Biohaven Pharmaceuticals also has applied for FDA approval on its oral CGRP antagonist rimegepant.

By Jane Anderson

New oral medications for acute migraine — one pending launch and two more that could be approved in the coming months — likely won’t shake up formulary coverage for a condition that’s largely treated by generic triptan medications, pharmacy benefit experts say.

Eli Lilly and Co. on Oct. 11 received FDA approval for its drug Reyvow (lasmiditan), an oral medication that’s the first serotonin (5-HT)1F receptor agonist to be approved for migraine. Meanwhile, Allergan on Nov. 19 said it’s on track for December FDA consideration of ubrogepant, an oral CGRP receptor antagonist for acute migraine. Biohaven Pharmaceuticals also has applied for FDA approval on its oral CGRP antagonist rimegepant.

Mesfin Tegenu, R.Ph., president of PerformRx, doesn’t expect widespread uptake of Reyvow. “The launch of lasmiditan will likely not change the formulary status quo when it hits the market, as it most likely will become a niche medication for patients inadequately controlled on triptans, or for those who cannot take triptans,” Tegenu tells AIS Health. “This is primarily due to warnings on the label for driving impairment and central nervous system depression.”

PBMs could have the chance to consider how to handle Reyvow and ubrogepant soon, although it’s not clear how soon. Eli Lilly hasn’t yet set a launch date for Reyvow, while Allergan said it expects ubrogepant to be the first approved oral CGRP receptor antagonist for the acute treatment of migraine.

“As with any new product, [ubrogepant] will need to be analyzed as part of the class of drugs for this indication,” Tegenu says. “Since this is the first oral version of a CGRP antagonist, it does have some administration advantages over injectable products.”

Payers can implement utilization management programs that direct use of these new drugs to those who have failed or cannot tolerate triptans, says Nicole Kjesbo, principal clinical program pharmacist with Prime Therapeutics LLC. “Additionally, payers will consider exclusion strategies and potentially value-based contracts as a means to manage cost and appropriate therapy,” she says.

CVS Health, Cigna Tout Benefits of PBM-Insurer Integration

November 20, 2019

Cigna Corp. and CVS Health Corp. — organizations that both recently combined a PBM and a health insurance business — are striving to prove to investors that they’re seeing valuable benefits from such vertical consolidation.

Executives from CVS, which purchased Aetna Inc. in late 2018, during the company’s third-quarter 2019 earnings call said that having such a diversified enterprise is helping it win over PBM clients for its Caremark division.

By Leslie Small

Cigna Corp. and CVS Health Corp. — organizations that both recently combined a PBM and a health insurance business — are striving to prove to investors that they’re seeing valuable benefits from such vertical consolidation.

Executives from CVS, which purchased Aetna Inc. in late 2018, during the company’s third-quarter 2019 earnings call said that having such a diversified enterprise is helping it win over PBM clients for its Caremark division.

For the 2020 PBM selling season, “our focus was to go to market with a more integrated medical-pharmacy offering,” said Karen Lynch, CVS Health executive vice president and Aetna president, according to a transcript of the call from Thomson Reuters. To that end, she noted that Caremark saw “increased traction in overall pharmacy penetration” for its employer-sponsored business, particularly among Aetna’s existing medical-benefits clients.

While CVS has won $4.9 billion in gross new business during the 2020 PBM selling season, — up from the $3.8 billion that it previously projected — “net new business is projected to be down -$6.4B overall (vs. -$7.4B previously),” due to the loss of Centene Corp.’s business and other non-renewals, Citi Research analyst Ralph Giacobbe wrote in a Nov. 6 note.

Cigna, which purchased Express Scripts Holding Co. in 2018, said a major driver of its better-than-expected quarterly financial results was the performance of its health services segment, which includes its PBM business. That book of business reported pretax operating earnings of $1.4 billion, which beat Wall Street’s consensus of $1.36 billion and far surpassed the $67 million it earned in the third quarter of 2018 — before Cigna’s purchase of Express Scripts closed.

“We were most encouraged by the PBM earnings step-up, increasing confidence [Cigna] will achieve its 2019 [earnings] target,” Jefferies analysts wrote in an Oct. 31 research note. Cigna raised its 2019 earnings per share estimate to a range of $16.80 to $17.00.

Independent Pharmacies Push Bill to Increase Access to Part D Preferred Networks

November 18, 2019

In the Medicare Part D market in 2020, preferred cost-sharing pharmacy networks continue to be king. But because independent pharmacies often find themselves shut out of such arrangements, recently introduced legislation is seeking to change that dynamic.

“The Part D plans have fully adopted preferred networks over the last few years,” says Adam Fein, Ph.D., president of Pembroke Consulting, Inc., and CEO of Drug Channels Institute. “The [retail] chains obviously have some different strategies but are looking for the foot traffic” that comes from offering lower cost sharing as part of a preferred network.

By Leslie Small

In the Medicare Part D market in 2020, preferred cost-sharing pharmacy networks continue to be king. But because independent pharmacies often find themselves shut out of such arrangements, recently introduced legislation is seeking to change that dynamic.

“The Part D plans have fully adopted preferred networks over the last few years,” says Adam Fein, Ph.D., president of Pembroke Consulting, Inc., and CEO of Drug Channels Institute. “The [retail] chains obviously have some different strategies but are looking for the foot traffic” that comes from offering lower cost sharing as part of a preferred network.

Meanwhile, many independent pharmacies and the pharmacy services administrative organizations (PSAOs) that represent them in negotiations with health plans are moving away from preferred Part D networks.

Fein says they “have concluded that the incremental traffic they’re going to get is not worth the profit they’re going to sacrifice.”

Ultimately, “I think the open question is, will this create access problems to preferred networks, and does CMS care?” he says.

The National Community Pharmacists Association (NCPA) isn’t counting on regulatory intervention. The organization is supporting a bill — introduced last month by U.S. Reps. Peter Welch (D-Vt.) and Morgan Griffith (R-Va.) — which would allow any pharmacy located in an underserved area to participate in a Part D preferred network as long as that pharmacy accepts the terms and conditions.

“We’re not asking for different terms and conditions, [or] higher reimbursement; we’re just asking to be able to see what the terms and conditions are to be in the preferred network and then make our best decision if we want to participate or not,” says Ronna Hauser, the president of policy and government affairs operations at NCPA.

The Pharmaceutical Care Management Association opposes the bill.

“The proposed any willing pharmacy provisions threaten the effectiveness of selective contracting with pharmacies as a tool for lowering costs,” says as statement from the PBM trade group.

CMS Updates Medicare Plan Finder Amid Advocates’ Concerns

October 30, 2019

Having already rolled out a major redesign of the Medicare Plan Finder in August, CMS recently revealed additional updates it made before the start of Medicare open enrollment on Oct. 15 — including a feature that advocates have said is critical to helping people find the best Part D plan.

In an Oct. 11 email, a CMS spokesperson said the agency “added a feature that allows Medicare Plan Finder users to sort plans by the total cost of estimated annual drug costs plus premiums.”

By Leslie Small

Having already rolled out a major redesign of the Medicare Plan Finder in August, CMS recently revealed additional updates it made before the start of Medicare open enrollment on Oct. 15 — including a feature that advocates have said is critical to helping people find the best Part D plan.

In an Oct. 11 email, a CMS spokesperson said the agency “added a feature that allows Medicare Plan Finder users to sort plans by the total cost of estimated annual drug costs plus premiums.”

So did CMS’s plan finder update ease Medicare beneficiary advocacy organizations’ concerns about the redesigned tool? Partially, says Ann Kayrish, the National Council on Aging’s senior program manager for Medicare. She says while it’s good that the sort function is back, the total-cost feature is not available on the plan-comparison page — which makes comparing plans more complicated than it was before.

“In general, the opening week of open enrollment has been rocky as some of the basic information like extra help subsidy levels and copay have been inaccurate, [and] pharmacy status and cost information inconsistent,” she adds. “To increase confidence in plan selections, counselors are spending time contacting the plan or Medicare to confirm coverage information.”

In its Oct. 11 email, CMS noted that it also implemented several other changes to the Medicare Plan Finder prior to open enrollment, including:

✦ The ability to display drug tier costs;
✦ A footnote for excluded drugs;
✦ An option to add mail order on the pharmacy selection page;
✦ A note about over-the-counter drugs on the drug lookup page; and
✦ An option to compare a third retail pharmacy when mail order isn’t selected.