Spotlight on Market Access

Beginning in April, California and New York will join a growing list of states that have opted to carve out prescription drug benefits from their Medicaid contracts with insurers, wagering that the state can do a better job at negotiating drug prices with manufacturers than managed care organizations and their contracted PBMs.

As more health systems are creating their own specialty pharmacies, two major players in the space are coming together. In mid-January, Shields Health Solutions unveiled a deal to purchase ExceleraRx Corp. for an undisclosed amount. The new company could provide these entities with more leverage when it comes to payer networks and manufacturer distribution.

As drug prices remain on an upward trajectory, many copayment assistance programs offered by pharmaceutical companies have helped patients — particularly those on costly specialty medications — stay adherent to their treatment regimens. But many payers have pushed back against these programs, contending that the offerings undermine their benefit designs. Copay accumulator and maximizer programs operated by payers are the latest attempt to circumvent the manufacturer assistance, and they are growing in popularity. Manufacturers should be tracking them to see how their therapies, as well as their patient-assistance programs, are impacted by these tactics.