Drug Coverage

New White Paper looks at the solutions and policy options of how to pay for high-cost gene therapies when there is still so much uncertainty about the outcomes and the durability of clinical benefits.

Researchers were unable to find a significant benefit for patients for the majority of cancer medications given accelerated FDA approval.

More than half of those survey by KFF who were disenrolled from Medicaid said they put off needed medical care because of costs.

Jeffrey Casberg, M.S., R.Ph., a senior vice president of clinical pharmacy at IPD Analytics LLC, a drug intelligence firm that advises payers and pharmaceutical companies, talks about how payers are thinking about weight-loss drugs.

Ventegra, which provides drug benefit solutions, is also converting to a nonprofit status, which will be completed June 30, 2024.

Caps on Medicare Part D cost sharing as a result of the Inflation Reduction Act, could reduce members’ financial incentive for switching to a biosimilar, suggests the newest Samsung Bioepis Quarterly Biosimilar Market Report.

Approved in late September 2022, Relyvrio will no longer be available for new amyotrophic lateral sclerosis (ALS) patients.

In 2025, the out-of-pocket cap and other Part D related provisions in the Inflation Reduction Act are projected to save women in Medicare an average of 28% in out-of-pocket costs, according to a new analysis from the Office of the Assistant Secretary for Planning and Evaluation.

Foluso Agboola discusses the framework that the Institute for Clinical and Economic Review has developed for assessing whether clinical trial populations represent the real-world patient population.

Ozempic and Rybelsus could become a target for Medicare price negotiation because of high spending and additional approved uses of the GLP-1 therapies.

Medicare Part B beneficiaries may save between $1 and $3,575 per average dose for the 41 drugs whose prices have risen higher than inflation.

Medicare and Medicaid will cover Wegovy for its recently approved indication to reduce the risk of cardiovascular death, heart attack and stroke in adults with cardiovascular disease and obesity.

This follows AstraZeneca’s and Boehringer Ingelheim’s announcements to also cap their asthma chronic obstructive pulmonary disease drugs at $35.

Lenmeldy is the first approved gene therapy to treat children with juvenile metachromatic leukodystrophy, a life-threatening inherited disease of the body’s metabolic system.

Zymfentra, with a price of $6,181.08 for two shots over four weeks, is approved as maintenance therapy for adults with ulcerative colitis and Crohn’s disease.

In a recent survey, payers said the Inflation Reduction Act will help lower patients’ out-of-pocket costs, but they were concerned about Medicare’s drug price negotiation and the IRA’s impact on formulary management.

AstraZeneca also said it had reduced the list price of Symbicort beginning Jan. 1, 2024.

The new collaboration gives Prime access to Capital Rx’s secure claims system JUDI, which Capital Rx leaders say was developed with enhanced security protocols.

In 2021, pediatric mental health conditions were associated with $31 billion in child spending and $59 billion in household spending, which made up 46.6% of all pediatric medical spending that year.

Michigan’s state Medicaid agency has signed an outcomes-based agreement for Lyfgenia patients with sickle cell disease. The agreement provides payers with risk sharing tied to vaso-occlusive events-related hospitalizations

Quantile Health is offering a new solution to help small health plans and self-insured employers fund gene therapy access — with a subscription model.

Fran Gregory, Pharm.D., of Cardinal Health, talks about a survey of ophthalmologists and their concerns about using biosimilars for retinal conditions.

Beginning in 2025, people with Medicare Part D drug coverage will have the option to pay out-of-pocket costs in monthly payments spread out over the year.

iDose TR was approved to reduce intraocular pressure in patients with ocular hypertension or open-angle glaucoma. It has a wholesale acquisition cost of $13,950 per dose/implant.

CarelonRx will provide digital coaching and wellness tools and incorporate behavioral and social health screenings for members.

The economy and healthcare costs are the issues voters want to hear about going into the 2024 presidential election, finds a survey by KFF.

Avalere’s Kolton Gustafson talks about CMS’ new model for negotiating outcomes-based agreements for sickle cell gene therapies for patients in state Medicaid programs.

Payers now covering Hadlima include United Healthcare, Prime Therapeutics and associated Blues plans, and some managed Medicare organizations.