Evernorth Drug Trend Report Highlights Pandemic's Impact on Utilization - MMIT
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Radar on Market Access
Actionable understandings from AIS Health’s in-depth coverage
April 2021 Evernorth Drug Trend Report Highlights
Pandemic’s Impact on Utilization
2 Bundled Payments in Employer
Plans Reduces Costs In the 2020 Drug Trend Report recently released by Evernorth, the
Cigna Corp. division added yet another chapter to the growing volume of
3 Copay Accumulator Usage Is on
the Rise
data detailing the profound effects that the COVID-19 pandemic has had
on health care, AIS health reported.
4 Reality Check: Acute Myeloid
Leukemia On the one hand, the massive amount of deferred routine and elective
health care utilization had a dampening effect on the number of new
medication users that Evernorth — which houses the PBM Express
Scripts — recorded in 2020. New users of asthma/COPD medications
dropped the most, by 7.1% year over year, likely reflecting the avoidance
of clinical settings among a group that is at particular risk of contracting
severe COVID-19.
Yet for commercial plans managed by Evernorth, the overall drug
utilization trend increased by 3.1%, compared with just 1.4% in 2019.
continued on p. 2
Interoperability Mandate Could Be an
Opportunity for Payers
Payers should look at the looming interoperability mandate as a
chance to gain a lasting advantage over their competitors, according to
two health care information technology (IT) experts.
In a March 26 webinar hosted by America’s Health Insurance Plans,
IBM Vice President Michael Curry of Watson Health and Jeff Rivkin, re-
search director for payer IT strategies at IDC Insights, said payers should
do more than meet the minimum interoperability standards.
“It’s just the tip of the iceberg. We’re going to see a lot of data ex-
changed. And if you don’t have a fairly robust platform to be able to do
that, you’re going to hurt next year, too,” Rivkin said.
Starting July 2021, HHS will require insurers that sell Medicare Ad-
vantage, Medicaid and CHIP managed care, and Affordable Care Act ex-
change plans to launch an application programming interface (API) that
will allow patients to access their complete medical and claims history on
© Managed Markets Insight & Technology, LLC | 1
MMIT’s Radar on Market Access April 2021
demand along with a continually updated provider ing payments decreased by $498 per episode, a
directory. Payers must also make all of their patient 27.7% relative decrease.
and claims data available to other insurers on a pay- “What we studied is a program that uses pro-
er-to-payer data exchange, which must be in place
vider-focused financial incentives to give providers
by January 2022.
plans to operate more efficiently, and then also
Rivkin said insurers should think about the pairs it with incentives to patients to use high-value
interoperability mandate and the mandate to release providers,” says study author Christopher Whaley, a
pricing information as the same project. Starting policy researcher in health care at the RAND Corp.
on Jan. 1, 2023, health plans must offer members “What we found is that, following the introduction
online shopping tools that allow them to see the of this program, overall episode costs fell by quite
negotiated rate between their provider and their a bit, and patient cost-sharing actually went to zero
plan, as well as a personalized estimate of their out- for patients who went through the program.”
of-pocket cost for 500 of the most shoppable items
“[The] bundled prices tend to be quite a bit lower
and services.
than if we just go through the normal insurance
“We’re all in the middle of those implemen- system,” Whaley says, noting that the providers give
tations, but there’s a huge downstream potential up higher prices for a guaranteed payment with no
for that data,” Curry explained. He also says the insurance road blocks or red tape. Implementation
pandemic-spurred telehealth boom has accelerated of the direct payments program also was associated
changes in consumer expectations.G with reductions in price variation, the study found.G
Bundled Payments in Em- Mental Health Drug Use Rose
continued from p. 1
ployer Plans Reduces Costs
“We saw higher utilization of prescription
A bundled payment program run by San Fran-
drugs to treat mental health issues associated with
cisco-based digital health company Carrum Health
the pandemic — anxiety, insomnia, and depres-
resulted in an average per-episode savings of more
sion,” says Evernorth Chief Innovation Officer
than $16,000 per orthopedic or surgical procedure,
Glen Stettin, M.D. “Among people with previously
a recent RAND Corp. analysis found.
diagnosed and common chronic conditions, such
Counting both procedures reimbursed under the as diabetes, high blood pressure and heart disease,
bundled payment program and procedures reim- many of which are risk factors for hospitalization
bursed outside the program, per-episode costs for and death from COVID-19, we also saw an increase
the three procedures studied — spinal fusion, major in utilization. This utilization was driven by higher
joint replacement and bariatric surgery — were medication adherence, itself a result of more people
10.7% lower overall, on average, than costs for com- choosing to fill their medication for 90 day vs. 30
parable procedures prior to implementation of the day supplies, and the convenience and safety of hav-
program. That added up to a total savings of $4,229 ing their medication delivered to their homes.”
per episode, the study found. Evernorth’s report also included statistics that
The analysis, published in the March issue of are typical of drug trend reports in more normal
Health Affairs, determined that employer-sponsored years. It reported 4% total trend across its commer-
health plans captured approximately 85% of the to- cial plans, 3% trend in Medicare, 1.4% in Medicaid
tal savings, or $3,582 per episode. Patient cost-shar- and 5.5% in health insurance exchange plans. G
© Managed Markets Insight & Technology, LLC. Contact support@mmitnetwork.com. |2
MMIT’s Radar on Market Access April 2021
Copay Accumulator Usage Is on the Rise
by Jinghong Chen
At least two-thirds of health insurance plans offered in the Affordable Care Act marketplaces in 32 states
include a copay accumulator adjustment policy (CAAP), which prevent drug manufacturer coupons from
counting toward patients’ annual deductibles or out-of-pocket cost limits, according to a recent study by The
AIDS Institute. Meanwhile, the Business Group on Health’s 2021 Large Employers’ Health Care Strategy and
Plan Design Survey showed that large companies are increasingly adopting copay accumulator programs to
reduce prescription drug costs, as 49% of employers said they either had such a program in place in 2020 or
were adding one in 2021, and another 14% planned one for 2022-2023.
% of Plans in States With Copay Accumulator Adjustment Policy Case Study: How Payments for a Prescription Drug Work
100% Plans 66%-99% Plans Plan Deductible: $4,600 Monthly Medication Cost: $1,680
ME
50%-65% Plans 33% Plans Annual Out-of-Pocket Maximum: $8,550 Copay Assistance Total: $7,200
State Law Prohibits CAAPs VT NH Cost-Sharing for Specialty Tier Prescription: 50% After Deductible Is Met
WA ID MT ND MN WI MI NY MA RI Plan Without a CAAP Plan With a CAAP
Copay Remaining Consumer Copay Remaining Consumer
OR UT WY SD IA IL OH PA NJ DE CT Assistance Deductible Pays Assistance Deductible Pays
CA NV CO NE MO IN WV VA DC MD Jan. $1,680 $2,920 $0 $1,680 $4,600 $0
Feb. $1,680 $1,240 $0 $1,680 $4,600 $0
AZ NM KS AR KY TN SC NC
March $1,240 $0 $0 $1,680 $4,600 $0
OK LA MS AL GA April $840 $0 $0 $1,680 $4,600 $0
May $840 $0 $0 $480 $3,400 $1,200
AK HI TX FL
June $840 $0 $0 $0 $1,720 $1,680
Large Employers’ Tactics to Address Coupon Cards July $80 $0 $760 $0 $40 $1,680
Aug. $0 $0 $590 $0 $0 $40
Already in Place in 2020 Adding in 2021
Sept. $0 $0 $0 $0 $0 $840
Considering for 2022/2023
Oct. $0 $0 $0 $0 $0 $840
Review coupon utilization data with PBM 44% 12% 15% Nov. $0 $0 $0 $0 $0 $840
Copay card accumulator program that does
not allow manufacturer coupons or copay Dec. $0 $0 $0 $0 $0 $840
cards to count toward the employee’s 39% 10% 14%
deductible and out-of-pocket maximum Total
$7,200 $1,350 $7,200 $7,960
Copay card accumulator program for
21% 7% 15% Insurer
specialty pharmaceuticals only
Collects $8,550 $15,160
Not cover medications that include a 2%
consumer coupon when a lower cost 10% 17%
alternative is available
Education campaign to help employees
8% 8% 29%
understand the costs and benefits of
manufacturer coupons
SOURCES: “Double-Dipping: Insurance Companies Profit at Patients’ Expense,” The AIDS Institute, March 2021. Visit https://bit.ly/3rgN3Td. “2021 Large Employers’
Health Care Strategy and Plan Design Survey,” Business Group on Health, August 2020. Visit https://bit.ly/3f8L692.
© Managed Markets Insight & Technology, LLC. Contact support@mmitnetwork.com. |3MMIT’s Radar on Market Access April 2021
Reality Check: Acute Myeloid Leukemia
Coverage
Pharmacy Benefit Commercial Health Exchange Medicare
Under the pharmacy benefit,
about 65% of the lives under
commercial formularies are
covered with utilization
management restrictions. Only
6% of the lives under Medicare
Part D formularies are not
covered for at least one of the
drugs.
Unrestricted Restricted Not Covered Not Listed
Medical Benefit Commercial Health Exchange Medicare
Under the medical benefit,
about 57% of the lives under
commercial policies are covered
with utilization management
restrictions. Meanwhile, almost
63% of the lives under Medicare
Part B policies have access to at
least one of the drugs without
utilization management
restrictions.
Unrestricted Restricted Not Covered Unknown
Key Players
DATA CUR R ENT AS O F Q 2 2021
© Managed Markets Insight & Technology, LLC. Contact support@mmitnetwork.com. |4MMIT’s Radar on Market Access April 2021 Reality Check: Acute Myeloid Leukemia Trends FDA Gave Venclexta Full Approval In October 2020, the FDA gave full approval to AbbVie Inc. and Roche Group unit Genentech USA, Inc.’s Venclexta (venetoclax) in combination with azacitidine, decitabine or low-dose cytarabine for the treatment of newly diagnosed acute myeloid leukemia in people at least 75 years old or who have comorbidities that preclude the use of intensive induction chemotherapy. The agency gave the companies accelerated approval for this indication on Nov. 21, 2018; the B-cell lymphoma-2 inhibitor’s initial approval was on April 11, 2016. Subscribers to AIS’s RADAR on Specialty Pharmacy may read the in-depth article online FDA Approves Onureg In September 2020, the FDA approved Bristol-Myers Squibb Co. unit Celgene Corp.’s Onureg (azacitidine) for continued treatment of people with acute myeloid leukemia who achieved first complete remission or complete remission with incomplete blood count recovery following intensive induction chemotherapy and are not able to complete intensive curative therapy. The agency gave the application priority review and orphan drug designation. Subscribers to AIS’s RADAR on Specialty Pharmacy may read the in-depth article online FDA Expands Mylotarg’s Indication In June 2020, the FDA expanded the indication of Pfizer Inc.’s Mylotarg (gemtuzumab ozogamicin) to include the treatment of newly diagnosed CD33- positive acute myeloid leukemia in people at least one month old. Dosing is based on body surface area. Drugs.com lists the price of a 4.5 mg vial as more than $9,091. Subscribers to AIS’s RADAR on Specialty Pharmacy may read the in-depth article online © Managed Markets Insight & Technology, LLC. Contact support@mmitnetwork.com. |5
MMIT’s Radar on Market Access April 2021
Reality Check: Acute Myeloid Leukemia
Key Findings
Market Events Drive Changes Characteristics
In March 2021, the FDA expanded the label for Jazz Pharma-
ceuticals plc’s Vyxeos (daunorubicin and cytarabine) to treat Indications
newly diagnosed therapy-related acute myeloid leukemia or
AML with myelodysplasia-related changes in people at least 1 Acute Myeloid
year old. In October 2020, the FDA gave full approval to Leukemia
AbbVie Inc. and Roche Group unit Genentech USA, Inc.’s
Venclexta (venetoclax) in combination with azacitidine, decit-
abine or low-dose cytarabine for the treatment of newly diag- Step-Therapy (ST)
nosed AML in people at least 75 years old or who have comor- Policies
bidities that preclude the use of intensive induction A review of ST policies for payer-con-
chemotherapy. trolled formularies:
Competitive Market Landscape No ST
An abundance of policies exists on the pharmacy side, particu- (99%)
larly for the newer targeted therapies. Payers want to make sure ST
these drugs are given to the appropriate patients at the appro- (1%)
priate point in therapy. Vyxeos is a combination of generics that
are already on the market in a liposomal injection. It will likely Single Step
have to step through the generic agents on the market before (35%)
being considered for reimbursement. Multiple Step
(65%)
Medical and Pharmacy Benefit Implications
Coverage for drugs in this indication is good and processes Prior-Authorization (PA)
through both the pharmacy and medical benefits. Idhifa, Ven-
clexta, Daurismo, Tibsovo, Xospata and Rydapt are oral and will
Policies
A review of PA policies for payer-con-
always process through the pharmacy benefit, while the injec-
trolled formularies:
tions Mylotarg and Vyxeos will be mainly through the medical
benefit. No PA
(19%)
PA
(81%)
Appropriate
(100%)
Restrictive
(0%)
DATA C U RRE N T AS O F Q 2 2021
© Managed Markets Insight & Technology, LLC. Contact support@mmitnetwork.com. |6About AIS Health The mission of AIS Health — a publishing and information company that has served the health care industry for more than 30 years — is to provide readers with an actionable understanding of the business of health care and pharmaceuticals. AIS Health’s in-depth writing covers the companies, people, catalysts and trends that create the richly textured contours of the health care and drug industry. AIS Health, which maintains journalistic independence from its parent company, MMIT, is committed to integrity in reporting and bringing transparency to health industry data. Learn more at https://AISHealth.com and https://AISHealthData.com. About MMIT MMIT is a product, solutions and advisory company that brings transparency to pharmacy and medical benefit information. MMIT partners with PBMs, payers and pharmaceutical manufacturers from P&T to point of care. We analyze market access trends and market readiness issues, while providing brand and market access solutions to navigate today’s rapidly changing health care market. MMIT has been 100% focused on market access for decades. We combine deep domain expertise around drug coverage with innovative technology and trusted data to answer key business questions related to access. MMIT data is trusted by U.S. physicians and sourced through a combination of direct partnerships with payers and PBMs and a technology infrastructure that is powered by smart business logic, artificial intelligence and human validation. Learn more at https://www.mmitnetwork.com. © Managed Markets Insight & Technology, LLC. Contact support@mmitnetwork.com.
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