AMCP 2022: Digital Therapeutics and the Medical, Pharmacy Benefit: Which Side Should They Go On?

Just pick a lane.

Those weren’t the exact words said during a discussion at the Academy of Managed Care Pharmacy’s annual meeting, AMCP 2022, this week about whether prescription digital therapeutics should be covered on the medical or the pharmaceutical benefit, but that was the sentiment.

Yuri Maricich, M.D., MBA, chief medical officer and head of development, Pear Therapeutics, said the company “hasn’t put a stake in the ground there” on the medical vs. pharmacy benefit question, but said that standardization is important.

Maricich

“I think what is most important for the whole industry, not just Pear, is that we establish coverage pathways. And that there is going to be a standardized coverage pathway that is clearly articulated for what developers need to bring to payers. It can be on medical, it can be on pharmacy. I think we are seeing right now there is more pharmacy,” Maricich said in a brief interview with Managed Healthcare Executive® after a session on coverage decisions on digital therapeutics that was developed by Pear and was not accredited for continuing education credit.

Maricich noted that continuous glucose monitors were paid for on both the medical and pharmacy benefit for a time after they were first on the market and then slowly migrated to the pharmacy benefit.

CMS promulgated a new medical code — known as a Healthcare Common Procedure Coding System (HCPCS) code — for digital behavioral therapies in late March. Maricich said the HCPCS doesn’t tilt digital therapeutics to either the pharmacy or medical benefits. “It more gives optionality,” he said

As an audience member during the education, Paul Jeffrey, pharmacy consultant and the recently retired senior director of pharmacy for Mass Health, the Massachusetts’ Medicaid program, made a plea: “Please chose one channels that it comes through.” Jeffrey said he spent two years advocating for coverage of digital behavioral health therapeutics by Mass Health, which resulted in a value-based contract with Pear. He noted that many people see the benefits of a digital therapeutics (he mentioned the relatively low cost and the cognitive-behavioral concepts that underlie how the therapeutics are experienced by patients) but said “it is a push against the tide right now.”

Jeffrey told Managed Healthcare Executive® after the session that AMCP has a policy of preferring that digital therapeutics be covered on the pharmacy benefit. He mentioned, though, that there are technologies that can mitigate the problems of having a therapy being covered on both the medical and pharmacy benefit,

Pat Gleason, PharmD, BCPS, FCCP, FAMCP, assistant vice president of Prime Therapeutics, a PBM that serves Blues Plans, and a member of the panel, said coverage decisions “are getting really muddy.” At an AMCP meeting in October 2021, Gleason discussed the value-based contract that Prime has negotiated with Pear. But at the session on Thursday, he described a multilayered review process in which a medical devices committee got involved. “I shared how it was going to work at Prime and then ran into what is the real world of coverage.”

“As a provider, I don’t really care,” said Arwen Podesta, M.D., a New Orleans psychiatrist, said about the medical vs. pharmacy benefit decision during the session on Thursda. Podesta, who was on the panel, added “I just ask that you all get on the same page.”