Radar on Drug Benefits

✦ CMS on Feb. 5 issued a proposed rule that would allow Medicare Part D sponsors to establish a second, “preferred” specialty drug tier with lower cost-sharing than the current specialty tier — after plan sponsors and PBMs indicated that would encourage the use of more preferred, less expensive agents. The proposed rule, which includes an array of changes to the Medicare Advantage and Part D programs for policy years 2021 and 2022, also would require each Part D plan to implement a Beneficiary Real Time Benefit Tool that lets enrollees view plan-provided, patient-specific, real-time formulary and benefit information. Visit https://go.cms.gov/38kOG9w to learn more.

✦ Geisinger Health Plan, which has a PBM contract with MedImpact through 2020, will switch to Philadelphia-based PBM PerformRx once that contract expires. Geisinger, which is based in Danville, Pa., will continue to manage its own formulary, provide utilization management services and handle customer service responsibilities, noted a press release. See https://bit.ly/2HqTzSZ.

OptumRx, which is owned by UnitedHealth Group, sorted the drugs likely to be approved this year into 17 treatment categories. Cancer-treating drugs were by far the most prevalent, with 44 likely approvals. Neurology followed with 29.

The health care industry’s largest payers continue to make the case that they are gaining — or project to gain — substantial benefits from integrating PBM businesses.

In particular, Cigna Corp. expects its integration of PBM Express Scripts to drive substantial prescription claim growth in the coming year, and Humana Inc. projects cost savings from its recent acquisition of hospice-focused PBM Enclara Pharmacia Inc.

With the cost of diabetes drugs still growing, PBMs and payers are looking for more innovative strategies to hold down costs. For some, that might include a strategy similar to the one recently unveiled by CVS Health Corp.’s Caremark unit. The plan, called RxZERO, offers a slimmer formulary for the diabetes drug class, but with no out-of-pocket costs for members. CVS says employers or insurers that pick this plan should expect to save about $30 annually per member.

Mike Schneider, a principal in the commercialization and market access practice at Avalere Health, says the plan is innovative. “You’ve seen Express Scripts do something where they’re offering specific insulins at very low out-of-pocket costs, but this is the first time I’ve seen a PBM come up with a way to eliminate out-of-pocket costs completely,” he tells AIS Health.

As part of long-awaited guidance that CMS issued to states on Jan. 30 outlining how they can test-drive a fixed federal Medicaid budget and more program flexibilities, the Trump administration invited states to try out something else that hasn’t been done before: implement a closed drug formulary for a portion of their Medicaid population.

“For the first time, participating states will have more negotiating power to manage drug costs by adopting a formulary similar to those provided in the commercial market, with special protections for individuals with HIV and behavioral health conditions,” CMS said in its press release unveiling the Healthy Adult Opportunity (HAO) demonstration, which states can apply for via a Section 1115 Medicaid waiver.