Spotlight on Market Access

Kaiser Permanente, founded in 1945 as a consolidation effort between local hospitals in California and an insurance group for construction employees, has since become the largest integrated delivery network in the U.S. The company operates 39 hospitals, employs more than 20,000 physicians in its medical groups and offers health insurance products in both the private and public sector markets. Kaiser’s seven regional managed care plans enroll more than 11 million lives in eight states plus the District of Columbia. The seven combined entities form the largest provider-sponsored insurer in the U.S., enrolling 29.5% of all provider-sponsored lives.

Humana Inc. and Anthem, Inc. are teaming up with hedge fund administrator SS&C Technologies Holdings, Inc. to create DomaniRx, a new joint venture that aims to offer a “best-in-class” PBM cloud-based claims adjudication platform. Humana will be the first customer for DomaniRx, the companies say, and industry observers predict a potential market among Blues plans and Medicare Advantage plans.

Health Care Service Corporation (HCSC) is the parent company of five large, member owned Blues insurers: Blue Cross and Blue Shield of Illinois, Montana, New Mexico, Oklahoma and Texas. The five subsidiaries enroll more than 16 million lives nationwide across the spectrum of health insurance products, though much of their membership is concentrated in Illinois and Texas. Originally founded in 1936 in Chicago as a prepaid insurance plan for hospital care, HCSC now enrolls more than half of all insured lives in Illinois.

PBMs have used formulary exclusions as an effective way to negotiate with manufacturers for several years. However, at least one payer has gotten more aggressive with its tactics to get members to move from an excluded drug to one with preferred status, dangling a financial incentive for members. That effort is facing pushback from several medical associations, but if it proves to be successful, other companies could follow suit, suggest industry experts.

With the FDA’s February 2021 approval of Bristol Myers Squibb’s Breyanzi, followed by another nod for the drugmaker’s Abecma just a few weeks later, there are now five chimeric antigen receptor T-cell (CAR-T) therapies on the market. Since they require administration at approved treatment centers, CAR-T drugs are most often covered under the medical benefit, though coverage under the pharmacy benefit isn’t unheard of. Among the most advantaged therapies are Novartis’ Kymriah, which holds covered or better status for more than 80% of all insured lives under the medical benefit, and Gilead Sciences’ Tecartus, following behind at 76%. The graphics below show how all five CAR-T therapies are covered under the pharmacy and medical benefit.