Radar on Drug Benefits

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.

✦ 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.