Radar on Drug Benefits

Health insurers are praising a provision in a recently proposed regulation that gives commercial plans greater leeway to run so-called copay accumulator programs, which prevent drug manufacturer coupons from counting toward patients’ annual deductibles or out-of-pocket cost limits. But the pharmaceutical industry slammed the proposal as “misguided” and liable to prevent patients from getting vital medications.

Regardless of whether CMS finalizes the copay accumulator provision in the proposed 2021 Notice of Benefit and Payment Parameters (NBPP) — an omnibus rule that primarily lays out regulations for Affordable Care Act-compliant plans — one health policy expert says such programs are a trend that will stick around as insurers look to lower the amount they spend on prescription drugs.

On March 3, St. Louis, Mo.-based integrated health system SSM Health revealed that Costco Wholesale Corp. purchased a minority stake in Navitus Health Solutions, the health system’s PBM that includes specialty pharmacy subsidiary Lumicera Health Services.

Ashraf Shehata, KPMG’s national sector leader for health care and life sciences, says this move is driven by a political push for greater drug price transparency, in particular with specialty pharmacy and branded pharmacy, and the need for a better cost model at PBMs.

The U.S. Preventive Services Task Force (USPSTF) has expanded its screening recommendation for hepatitis C virus (HCV), calling for all asymptomatic adults ages 18 through 79, including pregnant women, to be tested for the virus. That means all health plans must cover the expanded screening for free.

The B-level recommendation from USPSTF, released March 2, indicates there is high certainty that the net benefit of expanded HCV testing will be moderate, or there is moderate certainty that the net benefit will be moderate to substantial. The USPSTF also states that clinicians might consider testing adolescents with past or current injection drug use, although it stopped short of recommending testing. Over the past three years, the HCV drug regimens commonly used in adults have been approved for use in adolescents 12 years old and older.

Industry experts say the COVID-19 outbreak is unlikely to limit U.S. drug supplies in the short or middle term. However, they tell AIS Health that increased demand for longer-duration stocks of medication from self-isolating patients could strain supplies going forward.

“We are told at this point that we’re not seeing any [drug] shortages in the marketplace today,” Kelly McGrail-Pokuta, Prime Therapeutics’ vice president of pharmaceutical trade, told AIS Health on March 10.

✦ 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.