Health Plan Weekly

Starting in 2025, The Cigna Group’s Express Scripts will drop Humira (adalimumab) from its largest commercial formularies and instead cover only select biosimilars for the blockbuster autoimmune condition treatment.  

The move will make Express Scripts the second major PBM to prefer biosimilars over Humira after CVS Health Corp. did so in April. And it comes as both Cigna and CVS recently voiced their support for the FDA issuing draft guidance that would make it easier for biosimilars to get an “interchangeable” designation. 

People enrolled in Affordable Care Act marketplace plans had access to 40% of their local physicians in-network, on average, and those who enrolled in more expensive plans generally could access broader networks, according to a KFF analysis.

The analysis studied the percentage of physicians participating in the provider networks of Qualified Health Plans offered in the individual market in the federal and state ACA marketplaces in 2021. It found that only 4% of ACA exchange enrollees were in plans that included more than three-quarters of local doctors in-network, while 23% of enrollees were in a narrow network plan that included fewer than a quarter of the local doctors.

L.A. Care Health Plan and Health Net announced on Aug. 28 they have launched two programs that will collectively invest $90 million over five years to help people experiencing homelessness receive access to care. The health plans will invest $60 million in the L.A. County Field Medicine Program, in which 19 providers will provide coordinated care. They also will invest $30 million in the Skid Row Care Collaborative, which will include harm reduction services, extended hours for urgent care and pharmacies, and onsite specialty medical services in Los Angeles’s Skid Row neighborhood. The programs could assist about 85,000 Los Angeles residents, according to L.A. Care and Health Net, which is a division of Centene Corp. 

A federal district judge on Aug. 26 ruled in favor of TennCare beneficiaries who alleged the state’s Medicaid program caused thousands of residents to lose coverage after the introduction in 2019 of an electronic eligibility determination system, Fierce Healthcare reported on Aug. 28. “After years of litigation, plaintiffs have proven TennCare violated their rights under the Medicaid Act, the Due Process Clause of the Fourteenth Amendment, and the Americans with Disabilities Act,” the judge wrote. Fierce noted the state may appeal the court’s ruling. The Tennessee Justice Center, National Health Law Program and National Center for Law and Economic filed the lawsuit in March 2020.  

In what whistleblower attorneys say is a novel case, Humana Inc. has agreed to pay $90 million to settle False Claims Act allegations related to the Medicare Part D contracting process. The case was brought by a former employee who alleged Humana engaged in a “reverse-engineering” scheme to submit actuarially equivalent bids to CMS for Prescription Drug Plan (PDP) business that were based on inflated assumptions about the use of preferred pharmacies by low-income subsidy (LIS) members. Humana did not admit wrongdoing and stands by the merit of its assumptions. 

The suit, U.S. ex rel. Steven Scott v. Humana Inc. (3:18-CV-00061-GNS-CHL), was originally filed in January 2016 in the U.S. District Court for the Central District of California. It remained under seal until 2017, after the U.S. Dept. of Justice (DOJ) declined to intervene.  

With tens of millions of enrollees now dropped from the Medicaid rolls, a group of 189 health care organizations have taken another step they hope will add permanency to the program. The coalition, organized by the Association for Community Affiliated Plans (ACAP) and Families USA, sent a letter on Aug. 13 to congressional leaders calling for 12-month continuous enrollment for adults enrolled in Medicaid and the Children’s Health Insurance Program (CHIP). 

They asked for support of the Stabilize Medicaid and CHIP Coverage Act, which was introduced in the House by Rep. Debbie Dingell (D-Mich.) in September 2023 and in the Senate by Sen. Sherrod Brown (D-Ohio) the next month.