Radar on Drug Benefits

Editor’s Note: A previous version of this article misstated how OptumRx is covering Tecfidera, Ruxience, Rituxan and Truxima. This version has been corrected.

CVS Health Corp.’s Caremark will exclude 57 medications from its 2021 formulary and add six back. Meanwhile, UnitedHealth Group’s OptumRx subsidiary will exclude 19 medications and products while adding back five and implementing restrictions on others.

Following an Oct. 6 Supreme Court hearing, legal experts tell AIS Health that PBMs appear to have a good shot at prevailing in their challenge of a 2015 Arkansas law, which has major implications for how both health and drug benefits are regulated.

The case, Rutledge v. Pharmaceutical Care Management Association (PCMA), centers on a law known as Act 900 that aimed to protect independent pharmacies from what Arkansas Attorney General Leslie Rutledge calls the “abusive payment practices” of PBMs. Chiefly at issue is whether Arkansas can force PBMs to reimburse pharmacies for the price of any given drug set by the pharmacy’s wholesaler, even if that amount is higher than the maximum allowable cost (MAC) set by a PBM.

✦ Highmark Inc. said on Sept. 21 that it entered into an outcomes-based payment agreement with AstraZeneca PLC for Fasenra (benralizumab), which is an add-on treatment for patients age 12 and older with severe asthma. The agreement will hold AstraZeneca accountable for the clinical effectiveness of Fasenra when used by Highmark’s commercial and Medicare members. Previously, the insurer and drugmaker collaborated on an outcomes-based agreement for the asthma and chronic obstructive pulmonary disease drug Symbicort (budesonide/formoterol fumarate dihydrate), “one of the first outcomes-based agreements in the U.S. for the treatment of those chronic respiratory conditions.” Read more at https://bit.ly/2ROxyCA.

✦ Cigna Corp. on Sept. 16 said that it is rebranding its health services portfolio — which includes its PBM and specialty pharmacy businesses — as Evernorth. Tim Wentworth, who was the CEO of Express Scripts before Cigna acquired it, will be the CEO of the rebranded division. Cigna also unveiled new products that Evernorth will offer, including a “comprehensive fertility solution” called FamilyPath and Healthy Ways to Work, a suite of solutions that aims to help health plans and employees address challenges tied to COVID-19. Read more at https://bit.ly/3ks2vZD.

During a Sept. 17 virtual session of the America’s Health Insurance Plans (AHIP) National Conference on Medicare, Medicaid & Dual Eligibles, health insurance industry leaders were cautiously optimistic about the impact of CMS’s recent proposed rule seeking to promote value-based purchasing (VBP) for prescription drugs, despite mixed reviews from some industry stakeholders (RDB 7/9/20, p. 1).

In the regulation, which was proposed this summer, CMS outlined an updated interpretation of Medicaid “best price” rules — which dictate how rebates are calculated in the Medicaid Drug Rebate Program — by clarifying best price reporting requirements and enabling new structures including year-to-year scheduled prices that could change in relation to patient outcomes (RDB 6/5/20 p. 1).