insulin pricing and insurance issues - jdrf
TRANSCRIPT
INSULIN PRICING AND INSURANCE ISSUESPresented by: Jesse S. Bushman
January 12, 2019
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Agenda
Insulin Costs
Coverage2Control
Health Insurance Guide
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INSULIN COSTS
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INSULIN COSTS
The Public Perception
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INSULIN COSTS
What Has Been Happening – List Prices
From Business Insider: http://www.businessinsider.com/insulin-prices-increased-in-2017-2017-5
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INSULIN COSTS
The Drug Distribution Chain
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INSULIN COSTS
Insulin Rebate Levels
Credit Suisse analysis available at: https://research-doc.credit-suisse.com/docView?document_id=x744896&serialid=jqpXv9hakzYEokgnKchb4A1AQvWzTV95Lv0qoiZOu20%3D
MANUFACTURERS INCREASE LIST PRICES MOSTLY TO PAY LARGER REBATES
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Cefalu, W., Dawes, D., Gavlak, G., Goldman, D., Herman, W., Van Nuys, K., Powers, A., Taylor, S., and Yatvin, A. Insulin Access and Affordability Working Group: Conclusions and Recommendations. Diabetes Care 2018 May; dci180019. https://doi.org/10.2337/dci18-0019
MANUFACTURERS INCREASE LIST PRICES MOSTLY TO PAY LARGER REBATES
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Lantus Basaglar
Drug List Price $278.00 $234.00
Assumed Rebate Percent 60% 60%
Total Rebate - Dollars $166.80 $140.40
Assumed percent of rebate given to plan by PBM 94% 94%
Rebate dollars received by plan from PBM $156.79 $131.98
Rebate dollars retained by PBM $10.01 $8.42
Assumed patient coinsurance 20% 20%
Patient cost - dollars $55.60 $46.80
Plan cost, net of rebate dollars they receive from PBM and patient coinsurance $65.61 $55.22
Manufacturer's net (list price minus total rebate) $111.20 $93.60
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INSULIN COSTS
Biosimilars are NOT the Answer
List prices obtained from www.goodrx.com
Impact on Plan Medical/Pharmacy Costs of Passing Full Rebate to Patients at Point of Sale*
Plan Type
Traditional PPO Copay HDHP Coinsurance HDHP
Net Plan Per Member, Per Month Spend $433.91 $374.41 $372.89
Rebates Moved to Point of Sale $434.73 $377.03 $376.72
Change in Plan Costs - $ $0.82 $2.62 $384
Change in Plan Costs - % 0.2% 0.7% 1.0%
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INSULIN COSTS
JDRF’s Position – Pass Rebates to the Patient
Health insurers have an estimated median profit margin of 4-5%. So shifting rebates to the purchaser at point of sale is a big deal.
* Study by Milliman for PhRMA. Available at: https://www.phrma.org/report/point-of-sale-rebate-analysis-in-the-commercial-market
On March 6, UHC announced that rebates would be passed on to people in their fully insured employer plans, at the point of sale.
JDRF advocated with other major plans to follow UHC’s lead.
On March 27, Aetna announced a similar policy.
You can encourage your plan to do likewise through www.coverage2control.com
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INSULIN COSTS
UnitedHealthCare and Aetna Take Initiative
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COVERAGE2CONTROL
Coverage
Affordability
Choice
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COVERAGE2CONTROL
Campaign Goals
Online petition allowing T1D community to express support for Coverage2Control goals
Petition signers could follow up with customized email to their health plan
JDRF delivered copies of 53,000+ signature petition to 25 largest health plans
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COVERAGE2CONTROL
What the Campaign Accomplished
Anthem initially denied coverage for 670G but after JDRF input changed its mind and will now cover the device
All 25 of the nation’s largest insurers now cover the 670G
UnitedHealthCare covers two pumps after initially covering one
UnitedHealthCare and Aetna announce plans to extend drug rebates to purchasers at point of sale
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COVERAGE2CONTROL
Changes at Major Plans
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COVERAGE2CONTROL
Changes at BCBS NC
On November 2, JDRF sent letters to 23 major health plans asking them to pass drug rebates on to purchasers.
BCBS NC responded indicating that for their fully insured customers, they will begin doing so on 1/1/19.
Calls with Top 25 Health Plans
Had Call(s) Aetna Anthem BCBS AL BCBS FL BCBS MI BCBS MN BCBS NC BCBS TX CareFirst Cigna EmblemHealth Health Care Service
Corporation Highmark Horizon Humana
Independence Blue Cross
Kaiser Permanente Medica Health Plans UnitedHealthcare
Contacted Blue Shield CA,
Wellmark BCBS MA Cambia/Regence Premera
No Call BCBS TN
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COVERAGE2CONTROL
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Had Calls Call Scheduled/In Progress
Contacted No Call
CALL STATUS
Coverage of the First AP System (Medtronic 670G)
Aetna Anthem BCBS AL BCBS FL BCBS MA BCBS MI BCBS MN BCBS NC BCBS TN BCBS TX Blue Shield CA Cambia/Regence CareFirst Cigna
EmblemHealth Health Care Service
Corporation Highmark Horizon Humana Independence Blue
Cross Kaiser Permanente Medica Health Plans Premera UnitedHealthcare Wellmark
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COVERAGE2CONTROL
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Covers the Medtronic 670G
PLANS COVERING THE MEDTRONIC 670GALL OF THE TOP 25 PLANS IN THE COUNTRY COVER THE MEDTRONIC 670G
Exclusive Contract for Insulin Pump Coverage
No Exclusive Coverage Aetna Anthem BCBS AL BCBS FL BCBS MA BCBS MI BCBS MN BCBS NC BCBS TN BCBS TX Blue Shield CA CareFirst Cigna EmblemHealth Health Care Service
Corporation
Highmark Horizon Humana Independence Blue
Cross Kaiser Permanente Medica Health Plans
Limited Coverage UnitedHealthcare
Unknown Cambia/Regence Premera Wellmark
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COVERAGE2CONTROL
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No Exclusive Coverage Limited Coverage Unknown
EXCLUSIVE COVERAGE STATUS
Plan Coverage for Insulin
Express Scripts CVS Caremark Optum RX Prime
Therapeutics Aetna Anthem BCBS AL BCBS FL BCBS NC BCBS MA BCBS MN
BCBS TN BCBS TX Health Care
Services Corporation
Humana Independence
Blue Cross Kaiser Permanente Medica Health
Plans United Healthcare
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COVERAGE2CONTROL
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Yes No Unknown
INCLUDES INSULIN ON PREVENTIVE DRUG LISTTHESE PLANS AND PBMS INCLUDE INSULIN AND BLOOD GLUCOSE TEST STRIPS ON THEIR AVAILABLE PREVENTIVE DRUG LISTS
Encouraging JDRF volunteers to meet with their employers to talk about their benefit package
With NDVLC, JDRF staff connecting with key large employers Focus on insulin
To help, JDRF volunteers can respond to our survey (http://jdrf.org/c2c/employers)
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COVERAGE2CONTROL
JDRF Outreach to Large Employers
Employers Contacted to Date
General Motors
General Electric
UPS
Deloitte
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COVERAGE2CONTROL
On October 23, Express Scripts announced a new arrangement with a limited number of large employers under which they will be paid an administrative fee, rather than retaining a portion of the rebates they collect.
JDRF is going to try to explore this arrangement and better understand what might happen as a result.
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INSULIN COSTS
Express Scripts
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HEALTH INSURANCE GUIDE
JDRF Online T1D Health Insurance Guide
Help to choose and use your insurance
Resources integrated into existing TypeOneNationenvironment
Ongoing feedback will be solicited throughout the year
www.jdrf.org/insurance
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HEALTH INSURANCE GUIDE
How to Choose an Insurance Plan
How to Obtain Prior Authorizations
Understanding Common Issues Around Insulin, Insulin Pumps, CGMs and Test Strips
How to Apply for an Exception
What to Do When Your Insurance Company Denies You Coverage
Switching Issues: What to Do When You Need to Change Treatments
Working with Your Employer
Help with Your Costs
Insurance Terms and Resources
Medicare and Type 1 Diabetes27
JDRF Online T1D Health Insurance GuideHEALTH INSURANCE GUIDE
jdrf.org
Here’s Where You Can Find Us
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JESSE S. BUSHMANSenior Director, Health Policy
o: (202) 465-4128
m: (202) 997-5316
1400 K Street NW, Suite 1212
Washington DC 20005
CONTACT
THANK YOU