Radar on Drug Benefits

✦ The Institute for Clinical and Economic Review (ICER) and health care technology company Aetion are partnering to advance the use of real-world evidence (RWE) in assessing the cost-effectiveness of medicines, STAT reports. Aetion’s database of insurance company claims and related analytics allow ICER to use data generated outside of clinical trials in its evaluations of how drugs perform in the real world. According to Steven Pearson, ICER’s founder and president, RWE could be particularly useful in post-marketing assessments of drugs that were approved under accelerated pathways. Some of those products, especially for cancer or rare diseases, may come to market without large amounts of clinical trial data. ICER, a nonprofit research organization, will not pay Aetion under the terms of their agreement. The benefit to Aetion, the company’s CEO Carolyn Magill says, is in establishing its methodologies as a data standard. See http://bit.ly/2v6a9VG.

✦ On April 27, the U.S. Supreme Court will hear oral arguments in Arkansas’ appeal of a lower court ruling in Rutledge v. Pharmaceutical Care Management Association (PCMA) that impacts the state’s ability to regulate PBMs. According to the Northwest Arkansas Democrat-Gazette, Act 900 prohibits PBMs from differentially reimbursing affiliated and non-affiliated pharmacies for the same drug. It further requires PBMs to create a pharmacy reimbursement appeals process. PCMA asserted that the law limits health plans’ options and creates administrative burdens for PBMs. Arkansas Attorney General Leslie Rutledge (R) appealed after a lower court found that the law didn’t apply to employer-funded plans, which are regulated differently from health plans. That ruling was upheld on appeal. Previously, 32 states and the District of Columbia filed a brief in support of Arkansas. Several national and state pharmacy associations also support the state’s position. The high court’s decision is expected in June. Read more at http://bit.ly/2HYFkVm.

In its annual drug spending report, PBM giant Express Scripts said it kept total pharmacy spending in line with the consumer price index while reducing year-over-year (YoY) spending by 4.8% for its most tightly managed plans. While one consultant said there’s no way to verify such claims without a full review of Express Scripts’ methodology, he conceded that the PBM’s management techniques are probably due some credit.

The Cigna Corp. subsidiary said total member plan spending on prescription drugs rose by 2.3% last year. In addition, 37% of Express Scripts’ commercial plan clients spent less on drugs year over year in 2019. Express Scripts attributes those reductions in spending to the company’s “clinical solutions,” which it claims “saved patients and plans nearly $50 billion.”

A new study estimates that payers and patients spent a combined 26% more per person on prescription drugs in 2018 compared with 2014, with price growth far outstripping increased demand in driving drug spending. Analysts say a lack of price transparency and resulting market inefficiencies are contributing to the price growth.

Payers and patients spent a combined average of $1,118 per person on prescription drugs in 2018, according to a study published by the Health Care Cost Institute (HCCI). The study analyzed de-identified claims submitted to Aetna Inc., Humana Inc., Kaiser Permanente and UnitedHealthcare over the five-year period.

A generic version of Truvada coming on the market later this year will affect how payers cover pre-exposure prophylaxis (PrEP), experts tell AIS Health. PrEP is a daily medication used by people at risk of HIV to prevent infection. However, while the generic version will have an impact on PrEP coverage, experts say it will not significantly change how payers cover HIV drugs.

Gilead Sciences, Inc.’s Truvada (emtricitabine/tenofovir disoproxil fumarate) was approved by the FDA in 2004 to treat HIV infection in combination with other antiretroviral drugs. In 2012, it also was approved as the first drug for PrEP. Several generic versions of Truvada have been approved by the FDA but are not yet on the market. In March 2019, Gilead announced in a Securities and Exchange Commission filing that it had entered into an agreement with Teva Pharmaceutical Industries Ltd. to allow the company to launch its generic version on Sept. 30, 2020.

An earlier version of this story incorrectly said that the program initially was to start Jan. 1 but that the insurer pushed it back to July 1. The program launched Jan. 1, with a six-month transition period ending June 30.

BlueCross BlueShield of Tennessee, Inc. has found itself in the news recently but likely not for reasons the health plan might like: The insurer has received tremendous pushback from physicians on its decision to implement a policy requiring them to get provider-administered therapies from specialty pharmacies.