Spotlight on Market Access

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.

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.