On behalf of all of us at MedOne, we appreciate the opportunity to serve all our customers. We are especially appreciative in combination with our upcoming 25th anniversary in early April. Going back to our roots since being founded in 1999, we are passionate about being private and family-owned, and our 100% transparent, pass-through model that has existed since Day 1.
What's New in Pharmacy?
This newsletter provides a quick touchpoint on some news and happenings across the industry. It also allows us to say a friendly "hello" and connect to say thank you for being part of the MedOne family.
Our thoughts on the Ozempic lawsuit.
Have you heard? Over 10,000 patients have filed adverse event reports against specific GLP-1s (article link below), claiming inadequate warnings of severe side effects. The most common? Gastroparesis – a chronic condition where the nerves and muscles in the stomach wall severely weaken. GLP-1s were not originally designed to be an anti-obesity drug. They are a Type 2 diabetes therapy.
In 2023 at MedOne, Ozempic prior authorization denials were more than double the number of denials for any other drug. The major reason for the denials was due to off-label use (anti-obesity).
As new weight loss drugs (Wegovy, Zepbound, etc) come to market, MedOne has developed strategies to help employers know when and where it makes sense to cover these drugs.
View full article on LinkedIn.
Insulin price cap takes effect, lowering costs for many Americans.
View full article from USA Today.
Push for Stelara Biosimilar: The Next Humira
Stelara has held the position of J&J's leading revenue-generating drug since 2019, but its crucial patents began to expire last year. In June, Alvotech and its Israeli partner, Teva Pharmaceutical, entered into a settlement and licensing agreement with J&J for the introduction of the biosimilar, AVT04, no later than February 21, 2025, contingent upon receiving U.S. FDA approval. The regulatory decision is anticipated by April 16. Although a significant Stelara patent expired in the United States last year, J&J secured agreements with competitors to postpone the launch of their biosimilars until 2025. Amgen is set to be the first to introduce its comparable product, Wezlana, in the coming year.
View full article from Fierce Pharma.
Coverage Change for Vyvanse (Lisdexamfetamine)
ADHD Medication Shortage
We are heading into the second year of experiencing a nationwide shortage of ADHD medications such as Vyvanse, Adderall, and their generic alternatives. Regardless of the cause, MedOne is committed to ensure members have access to an appropriate prescription at an affordable cost.
Formulary Change
Some brands like Vyvanse are excluded from the Performance Formulary due to the availability of generic alternatives. The MedOne Formulary Subcommittee meets weekly to evaluate market changes and adjust formularies as necessary.
Recently, the Subcommittee discussed the shortage of ADHD medications. They evaluated the cost impact and the impact on clinical outcomes and member/client satisfaction and determined it was best to allow brand Vyvanse on formulary in a non-preferred tier until the generic becomes readily available.
Contact your MedOne Account Management team for additional details.
Read more information about the formulary change.
Regulation Watch
Federal Trade Commission Chair Targets PBMs
Amidst an FTC investigation of PBM middlemen, Commission Chair Lina Khan relays the “Big 3” haven't filly cooperated. “So far, the PBMs have not fully complied with our orders to turn over documents and data,” she said. “FTC orders are not suggestions and we will not hesitate to use the full extent of our legal authorities to mandate compliance.”
View full article from Ohio Capital Journal.
Government Entities Launch Inquiry
The FTC, the Department of Justice's (DOJ) Antitrust Division, and the U.S. Department of Health and Human Services launched and RFI on “deals conducted by health systems, private, payers, private equity funds, and other alternative asset managers that involve heath care provider, facilities, or ancillart products or services.”
View full article from The FTC.
Consolidated Appropriations Act
Under the Consolidated Appropriations Act (CAA), self-funded group health plans are required to report data annually regarding prescription drugs and health care spending to the Departments of Health and Human Services, Labor, and Treasury (Tri-Agencies). The next due date for submission is June 1, 2024, and will encompass 2023 data. This data is submitted via a Centers for Medicare & Medicaid Services (CMS) web portal.
To support our clients’ self-funding group health plans, MedOne will submit the P2 and D3 – D8 files along with a narrative response for plans directly to CMS. (Please note, medical administrators may also be required to send some of these files, as per the CAA.) Our submission will include plans which had active coverage with MedOne during the reference year (2023).
If you have questions about the MedOne submission process, please reach out to Laurie Stowe, VP of Account Management, at lstowe@medone-rx.com.
Cyber Attack on Change Healthcare Carries Worldwide Impact
What Happened:
As you may know, all pharmacies hire a switch vendor to route claims from their pharmacy management system to PBMs like MedOne. One significant switch vendor is Change Healthcare who is experiencing an outage (starting around 11:05 AM EST on 2/21/2024) preventing claims from reaching PBMs like MedOne. Various pharmacies and PBMs have confirmed this is an industry-wide issue and not isolated to MedOne. We're now learning, it's not isolated to pharmacy claims either.
Service to MedOne members was impacted for a short time and while the Change Healthcare outage persists, MedOne found an alternative solution.
Our Solution
MedOne was able to establish connectivity to receive claims from an alternative switch vendor named RelayHealth.
All pharmacies using RelayHealth will now be able to successfully submit claims to MedOne. While we believe many pharmacies have pivoted to RelayHealth, there still may be pharmacies unable to process claims. For those instances, we have some alternatives and workarounds in place. Please contact your MedOne Account Management team for additional details.
Read more about the outage from WIRED.
Save the Date!
MedOne is celebrating 25 years in business here in April!
If you're local to the Dubuque area, please plan on joining us for an open house and ribbon cutting on Friday, April 12 from 7:30-10:00AM.