Spotlight on Market Access

Change is coming to drug reimbursement under the Medicare and Medicaid programs: CMS is set to implement a new Medicaid rule providing flexibility for value-based drug purchasing and is considering how best to incorporate value-based purchasing into parts of the Medicare program, a panel of experts said recently.

UnitedHealthcare (UHC), the health insurance unit of UnitedHealth Group, Inc., is the largest health insurer in the U.S., offering products across all sectors. Nationally, UHC is the top insurer in the group risk, administrative services only (ASO) and Medicare Advantage (MA) markets. As of March 2021, United controls a whopping 26.7% of the national MA market, and has expanded its presence significantly year over year since 2018.

Ohio recently cleared a key hurdle in its plan to revamp how Medicaid enrollees’ pharmacy benefits are managed, choosing Gainwell Technologies as the single PBM that will replace big-name firms including Cigna Corp.’s Express Scripts, CVS Heath Corp.’s Caremark, UnitedHealth Group’s OptumRx and Centene Corp.’s Envolve Pharmacy Solutions.

California and other states that are carving out drug benefits and implementing one single formulary within their state Medicaid programs likely will pose both a challenge and an opportunity for drug manufacturers seeking Medicaid market share for their products, stakeholders say.

As of this year, five states have generally carved out their pharmacy benefits from their Medicaid managed care organization (MCO) contracts: Missouri, North Dakota, Tennessee, West Virginia and Wisconsin. That means the states themselves, rather than the Medicaid MCOs and their affiliated PBMs, now are managing their pharmacy benefits. New York’s and California’s carve-outs are scheduled to take effect this spring.

People being treated for advanced prostate cancer now have a new oral option, offering patients the ability to not have to visit a provider for administration — an especially welcome alternative during the COVID-19 pandemic. Industry experts point to an array of reasons as to why the new drug should expect to get a lot of use. And a recent Zitter Insights survey indicates that the majority of oncologist respondents likely will prescribe it, with many saying they expect to favor it over the current standard of care.