Radar on Drug Benefits

SCAN Health Plan, a California-based Medicare Advantage insurer, is pushing further into the world of virtual drug management with an investment in Arine, a software vendor with a focus on artificial intelligence-backed medical management solutions.

On Oct. 19, SCAN Group, the carrier’s parent company, announced it had taken a minority stake in the vendor, with whom it had a previously established client relationship. The investment in Arine, whose software platform relies on predictive analytics to drive medication adherence, gives SCAN the ability to target specific populations and tailor messages individually to members, including to traditionally underserved populations, according to Binoy Bhansali, corporate vice president of corporate development for SCAN Group.

President Joe Biden recently nominated former FDA Commissioner Robert Califf, M.D., to run the agency once more, ending nearly a year of temporary leadership under Acting Commissioner Janet Woodcock, M.D. One insider says that Califf might look to reform and improve the accelerated approval pathway following the controversial Aduhelm (aducanumab) approval earlier this year.

Califf previously led the FDA during the Obama administration, running the agency for roughly the last two years of Obama’s term. Califf advocates for using “real-world evidence” in addition to clinical trial data in medical approvals. Aduhelm, an Alzheimer’s drug, was approved without such data, though studies of the drug relying on real-world evidence — which takes into account electronic medical record and insurance claims data — are underway. During Califf’s initial tenure, Sarepta Therapeutics’ eteplirsen, a muscular dystrophy drug, also earned accelerated approval despite a large outcry from medical researchers.

Plan sponsors’ overall satisfaction with their PBMs increased from 8.0 on a 1-10 scale in 2020 to 8.2 in 2021, according to Pharmaceutical Strategies Group’s 2021 Pharmacy Benefit Manager Customer Satisfaction Report. Based on surveys completed by 291 plan sponsors who provide pharmacy benefits to their employees, the report found that PBMs with 20 million or fewer members tend to have higher satisfaction ratings than larger PBMs. Average satisfaction was highest for PBMs’ opioid management programs, while gene therapy financial protection programs rated the lowest and only 13% of the respondents used such programs. Among PBMs with more than 20 million members, MedImpact scored the highest overall satisfaction rate (8.5). 

Cigna Corp.’s Express Scripts is offering its health plan and employer clients a “first-of-its-kind” option to cover over-the-counter COVID-19 tests. Starting Jan. 1, 2022, members of participating plans will be able to choose an applicable COVID-19 test kit at a participating in-network pharmacy and show their Express Scripts member ID card at checkout to process the kit through their pharmacy benefit. Plans that opt into the new solution can set a copay for the COVID tests either at a discounted rate or $0. “Our new COVID-19 test kit solution creates more affordable and easily accessible testing options, ultimately contributing to safer communities and less disruption in our daily lives,” said Amy Bricker, president of Express Scripts.

wo new PBMs entered the game in recent weeks: EmsanaRx, a not-for-profit venture owned by the Purchaser Business Group on Health (PBGH), and CostPlus PBM, a startup funded by venture capitalist and Dallas Mavericks owner Mark Cuban as part of his larger foray into the pharmaceutical business. Like other recent PBM startups, both ventures claim they will be more transparent and client-focused than the Big Three PBMs (Cigna Corp.’s Express Scripts, CVS Health Corp.’s Caremark and UnitedHealth Group’s OptumRx) — but health care insiders say those promises are hard to keep.

Both PBMs will begin serving clients in 2023. EmsanaRx will start by serving a small number of PBGH members that year. It will eventually be open to any purchasing entity but will not pursue business on a large scale. On the other hand, CostPlus PBM has aggressive growth targets: Its CEO, Alex Oshmyansky, M.D., Ph.D., tells AIS Health, a division of MMIT, that the company will “absolutely” seek to grow to Big Three size.