Radar on Drug Benefits

A promised executive order that would tie drug prices to their costs in other countries has yet to emerge, although President Donald Trump has promoted the order as part of his re-election campaign. Meanwhile, payers and PBMs are continuing to push back against three executive orders the Trump administration issued in July with the intention of lowering drug prices, one of which would overhaul the Medicare Part D prescription drug rebate system.

Avalere Health founder Dan Mendelson tells AIS Health that the disjointed rollout of the executive orders doesn’t alter their impact.

With the deadline approaching for Medicare Part D plans to implement a Real Time Benefit Tool (RTBT) — which informs prescribers when lower-cost alternative therapies are available under a beneficiary’s drug benefit — one PBM is offering up a new tool to fulfill the requirement.

Prime Therapeutics, LLC, a PBM collectively owned by 18 Blue Cross and Blue Shield plans, said on Sept. 2 that it is rolling out a tool called Real Time Benefit Check, which works through the ePrescribe function of a health care provider’s electronic health record (EHR) system. The idea is to offer providers “comprehensive information so they can easily prescribe the most appropriate and cost-effective medications at the point of care,” per a news release from the PBM.

With the economic fallout from COVID-19 driving billions of dollars in projected state budget shortfalls over the next few years, officials around the country are taking a hard look at how to cut costs. Against that backdrop, more states may consider replicating a concept pioneered by New Jersey: a reverse-auction PBM procurement model.

Trish Riley, executive director of the National Academy for State Health Policy (NASHP), tells AIS Health that states “definitely are” looking at the idea more closely, “particularly as the budgets get tighter in state governments.”

Cigna Corp.-owned PBM Express Scripts says it will exclude nearly 150 brand medications in its 2021 National Preferred Formulary. But one consultant says only a handful of the exclusions — notably, Novartis Pharmaceuticals Corp.’s biologic Cosentyx (secukinumab) and Amgen, Inc.’s bone marrow stimulant Neulasta (pegfilgrastim) — are likely to cause much member disruption.

“They [Express Scripts] essentially said 98.7% [of customers] don’t really experience any disruption with their formulary changes,” says Stephen Wolff, Pharm.D., R.Ph., pharmacy management consultant for Milliman Inc. He notes that many of the exclusions were multi-source brands, which aren’t likely to be particularly disruptive for members. “So we’re really thinking about those 45 or so single source brands that they excluded,” Wolff tells AIS Health.

✦ When the size, shape, color and markings on their prescription pills change without explanation, it can hamper patients’ medication adherence, according to a study published on Aug. 12 in the American Journal of Managed Care. The study outlined results of two 2016 surveys: one conducted on patients 50 years and older taking generic drugs for depression, diabetes, epilepsy, HIV, hyperlipidemia or hypertension, and one conducted on licensed pharmacists. The pharmacists acknowledged that pill appearance changes frequently in their pharmacies, and more than three-fourths of respondents reported notifying patients about those changes often, either verbally or through a sticker on pill bottles. Yet less than half of patient respondents reported being notified of pill-appearance changes — something 82% said they would prefer pharmacists do. “Among patients who reported experiencing a change, 12% reported stopping their medication or using it less frequently,” the study said. Read more at https://bit.ly/3aVUbxD.

✦ Humana Inc. is suing a Florida-based company called QuivvyTech and multiple doctors, alleging that they ran an “organized, elaborate telemedicine scheme” targeting Humana members. According to the suit, which was filed on Aug. 20, telemarketers cold-called Humana members and “tricked them into talking about common ailments,” then sent that information to doctors who electronically prescribed high-cost topical creams to the members without ever actually speaking to them. The fraudulent prescriptions were then wired to the co-conspirator pharmacies, which dispensed the medications to the targeted members and “billed Humana millions of dollars for these fraudulent prescription claims,” the complaint alleged. Humana members, meanwhile, “often were left confused, irate and in the possession of unwanted expensive creams.” View the lawsuit at https://bit.ly/34vL0Tx.