Page 1


TABLE OF CONTENTS

02

Introduction

06

Medicaid Fee-forService Trends

24

Pipeline and Forecasting

EDITORIAL STAFF Stephanie Stevens, MPH Director, Research and Publications

CONTRIBUTORS

03

Key Trends and Insights

09

Class and Drug Trends

25

Methodology

Meredith Delk, Ph.D., MSW Senior Vice President, General Manager, Government Affairs Douglas Brown, R.Ph., MBA Consultant, Government Markets Christopher Andrews, Pharm.D. Vice President, Value-Based Purchasing

04

Medicaid Pharmacy Economics

11

Key Therapeutic Classes by Net Dollar Impact

26

Glossary

Troy Phelps Senior Director, Analytics

© 2020 Magellan Rx Management LLC. Magellan Rx Management 2020 Medicaid Trend Report™ is published in conjunction with D Custom. All rights reserved. All trademarks are the property of their respective owners. The content — including text, graphics, images and information obtained from third parties, licensors, and other material (“content”) — is for informational purposes only. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Figures may be reprinted with the following citation: “Magellan Rx Management Medicaid Trend Report™, Fifth Edition, © 2020. Used with permission.”

1

MAGELLAN RX MEDICAID PHARMACY TREND REPORT / 2020


INTRODUCTION Magellan Rx Management is pleased to present the fifth edition of the Magellan Rx Management Medicaid Pharmacy Trend Report, the industry’s leading report exclusively detailing trends in the Medicaid pharmacy fee-for-service (FFS) space and the only detailed source examining Medicaid FFS gross and net drug spend trends.* In 2019, as in prior years, we saw state legislatures struggle to balance the growing cost of state Medicaid programs with state budget projections. Across the country, states expanded authority for state Medicaid agencies to negotiate additional discounts with manufacturers for high-cost drugs, increased the use of clinical criteria, furthered the reach of preferred drug list programs, and took steps to introduce the use of outcomes-based contracting. States also continued to move the pharmacy benefit from Medicaid managed care organizations (MCOs) back to Medicaid fee-for-service (FFS) to take advantage of lucrative federal and supplemental rebate programs. Some used drug utilization review (DUR) boards and pharmacy and therapeutics (P&T) committees to leverage clinical evidence and financial information in hopes of lowering state costs for the most expensive Medicaid covered drugs. The four-year FFS trend clearly illustrates the variability in the Medicaid program and the inherent challenges states faced. The trend continued to grow after hitting its lowest point in 2017 (see figure 1). Specialty growth continued to drive this increasing trend and is rapidly approaching a forecast we have made since the first edition of this report in 2016 — that specialty drugs will account for 50% of net drug spend in Medicaid by 2020. In 2019, specialty accounted for 48.5% of net spend while making up just 1.3% of utilization.

year-over-year increase of 9.7% and 12.9%, respectively. That trend continued into early 2019, with a first-quarter increase of 11.7%. Fortunately, the balance of the quarters trended in single digits to bring down the trend for 2019. States continued to explore and implement efforts to counterbalance the increasing cost of specialty drugs with unique payment models such as subscription- and outcomes-based contracting. While still early in their life cycle, these models are critical for states that want to move the conversation from volume to value. One area of consistency in Medicaid FFS was the Top 5 drug classes, which remained the same yearover-year. HIV/AIDS and antipsychotics accounted for more than 20% of total net spend, and the Top 5 classes accounted for almost 40% (see figure 2). As the Medicaid Pharmacy Trend Report turns five, and the Medicaid prescription drug landscape continues to evolve, we strive to keep you ahead of the trends and challenges in the Medicaid FFS space. In this report, our now-standard in-depth analysis of the top drug classes has expanded to include an additional six categories and detail a better picture of classes with a significant net dollar impact. As usual, we have included a forecast of Medicaid FFS trend as well as pipeline updates.

Aligning with the increased trend, as noted in our annual webinar last year, we have kept an eye on a micro-trend emerging in third- and fourth-quarter specialty net cost per claim data, which showed a

Thank you for your continued interest in the Medicaid Pharmacy Trend Report. We will continue to bring you these important trends to drive conversations and uncover strategic opportunities to better manage Medicaid pharmacy programs in the coming years.

FIGURE 1: 4-YEAR NET COST PER CLAIM TREND

FIGURE 2: TOP 5 CLASSES BY NET SPEND 2019

Traditional

Specialty

Overall Trend

HIV/AIDS Antipsychotics Hemophilia Treatment Anticonvulsants Stimulants and Related Agents Other

12.3% 8.4% 0

0

7.5%

20.5% 1.9% -5.1%

4.6% -4.4% -9.7%

6.1% 0.8% -2.6%

8.6% 4.3% -0.4%

2016

2017

2018

2019

60.9%

6.0%

4.9%

Please note: COVID-19 did not impact these data, as this report covers 2018-2019 trends.

*

2020 / MAGELLANRX.COM/TRENDREPORT

2


KEY TRENDS AND INSIGHTS Overall Trends

Traditional vs. Specialty Impact

FIGURE 3: 2019 TREND IN NET SPEND

Claim volume ratio remains virtually unchanged while total net spend on specialty drugs increased by 2.4%. Specialty drugs will account for 50% of the total net drug spend in Medicaid by 2020.

4.3%

FIGURE 6: TOTAL NET COST

FIGURE 5: CLAIM VOLUME

Overall Trend

Traditional

-0.4%

8.6%

Traditional Trend

Specialty Trend

Specialty

Traditional

1.3%

Specialty

1.3% 48.5%

46.1%

-0.10

-2.0%

$

Utilization Trend

Cost Trend

141.12

Utilization Trend

Cost Trend

FIGURE 4: OVERALL COST TREND 2018-2019 2018

2019

2018

2019

98.7%

98.7%

-0.9%

$

2018 53.9%

FIGURE 7: TRADITIONAL COST TREND

% Change

2018

2019

2019 51.5%

FIGURE 8: SPECIALTY COST TREND

% Change

2018

2019

% Change

5.4%

3.7%

3.7%

117.57

3,631.62

$

$

71.26

$

113.36

$

4.3%

8.6%

3,445.12

$

69.92

$

1,781.90

47.77

$

$

-0.4%

45.81

1,640.78

$

$

25.02

$

Gross Cost per Claim

3

Net Cost per Claim

MAGELLAN RX MEDICAID PHARMACY TREND REPORT / 2020

Gross Cost per Claim

24.92

$

Net Cost per Claim

Gross Cost per Claim

Net Cost per Claim


MEDICAID PHARMACY ECONOMICS The Medicaid pharmacy pricing landscape has remained largely unchanged over the five years Magellan Rx has produced this report. The basic tenet of the program is the same — manufacturers agree to a base (or “federal”) rebate in exchange for mandatory pharmacy coverage for their products by states that provide the Medicaid pharmacy benefit (currently all states and the District of Columbia). Through this agreement with the Centers for Medicare & Medicaid Services (CMS), manufacturers gain “payable” status everywhere. Medicaid rules permit individual states or a group of states to contract additional (or “supplemental”) rebates to further reduce the net cost of pharmaceuticals. These contracts are protected by Medicaid’s best price exemption. The pharmacy benefit is included in the Federal Medical Assistance Percentage (FMAP), so states share supplemental rebates, as they do federal rebates, with the federal government. The other rebate factor in the equation — the rebate offset amount (ROA) — continues to go entirely to the federal government and constitutes a small portion (roughly 2.5%) of the federal rebate. In 2019, the average total discount was 59.4% (54.6% federal and 4.8% supplemental). In 2019, the CMS continued to implement technical revisions to the rebate calculation to address the unintended consequences of the 2010 Affordable Care Act (ACA) language. This technical change was recommended by the Medicaid and CHIP Payment and Access Commission (MACPAC). In 2018, the president’s budget changed the rebate offset amount calculation in order to clarify the impact on line-extension drugs. The 2019 budget changed the blended average manufacturer price (AMP) calculation to remove any authorized generic’s AMP from the brand AMP calculation, effectively restoring AMP to pre-authorized generic levels on branded drugs. This move benefited Medicaid programs because federal rebates are proportional to AMP; therefore, increased AMP results in increased federal rebates. Multisource brands saw the desired effect in the fourth-quarter 2019 CMS rebate file as many federal rebates returned to pre-generic-launch levels. Going into 2020, more states may take advantage of brands with significant

utilization and a lower net cost than their generic equivalents. While Medicaid programs must reimburse for utilization of these covered products, they still incorporate many utilization management tools managed care organizations (MCOs) use to drive prescription use according to product preferred drug list (PDL) statuses. Along with the benefit of the best price exemption, these tools help Medicaid programs successfully manage the pharmacy benefit to the lowest net cost possible. Possibly the biggest change to Medicaid pharmacy over the past five years is states’ uptake of the single-PDL or unified-PDL program model. Ten of 26 states included in this report have implemented the single-PDL program model, three in 2019 alone — and there will be more in 2020 and 2021. The economics that ensure that state Medicaid programs pay the lowest net cost available combined with the favorable ACA allowance for collection of federal and (under prescribed conditions) supplemental rebates for Medicaid MCO utilization make the single-PDL trend likely to continue.

Key Points in Medicaid Economics » L owest net cost is calculated net of federal, supplemental, and offset rebates.

alternatives, each with higher discounts and lower net costs than the new drug. With a pharmacy reimbursement cost of $100, the net cost to the state is $76.90 ($100 minus 23.1%, or $23.10). To be competitive, the manufacturer of the new brand will offer an additional discount — a supplemental rebate — to lower the net cost from $76.90 to a competitive price of $50. The value of the supplemental rebate at time zero is thus equal to $26.90, and the total discount is 50%, or $50. As time progresses, manufacturer pricing actions drive up the total discounts.. Still, due to the inverse relationship between supplemental and federal rebates, supplemental discounts decline over time as the total discount increases (see figure 9). As the patent expiration approaches, the manufacturer generally increases the cost of the drug and the Consumer Price Index for Urban Consumers (CPI-U) penalty accelerates the growth of the federal rebate in the quarters just prior to that event.

FIGURE 9: MEDICAID PHARMACY ECONOMICS Brand Drug Price

» D  o not chase supplemental rebates at the expense of lowest net cost.

$100.00

» B  rand drugs can be less expensive than their generic equivalents and can save states millions of dollars.

$50.00

The Economics To understand Medicaid economics at the drug level, assume pharmacy reimbursement, wholesale acquisition cost (WAC), and AMP are all the same. A new brand drug enters the market with a minimum mandatory rebate of 23.1% of AMP. This drug enters a competitive class with three clinically equivalent therapeutic

Generic Drug Price

State Net Drug Cost

Supplemental Rebate

State Net Drug Cost

$23.10

Brand Federal Rebate

(Greater of 23.1% AMP or AMP Best Price + CPI-U Penalty)

New Drug Introduction

Time

Generic Federal Rebate

(13% AMP + CPI-U Penalty)

Patent Expiration/ Generic Introduction

2020 / MAGELLANRX.COM/TRENDREPORT

4


FIGURE 10: BRAND AND GENERIC NET COST PER CLAIM Brand

Generic Generic becomes cost-effective over brand

50K 150K

$ $

Q1

50K 130K

50K 115K

$

$

$

$

Q2

Q3

50K 100K

$ $

Q4

50K 85K

50K 45K

Brand Two-Year Average: $400K

50K 35K

50K 25K

$

$

$

$

$

$

$

$

Q1

Q2

2018

Q3

Generic Two-Year Average: $685K

Q4

2019

Generic Impact At patent expiration, commercial plans welcome the launch of a generic as an opportunity to lower reimbursement and overall drug cost. In Medicaid, generic launches require careful thought and financial evaluation. Generics typically enter the market at a discounted price point relative to the brand’s full price but with a federal rebate at only 13% of AMP. The net cost of a brand drug can be markedly less than the generic at this time (see figure 10). Factors affecting the availability of this new generic can cause the net cost of the generic to remain relatively high for as long as six months to

multiple years. In 2019, brand-over-generic programs accounted for $320 million in savings for states included in this report, with an average of $70 saved per claim.

of generic efficiency requires states to classify brand and generic drugs not by their formal label name but by their CMS drug class indicator: single-source, innovator multisource, or non-innovator multisource. The impact to FFS is significant because authorized generics (AGs) that have a non-innovator multisource (generic) label name pay an innovator multisource (brand) federal rebate and thus get counted as brand drugs by the CMS. Over 2018 and 2019, states averaged an 85.6% effective generic dispensing rate (GDR) when defined as drugs that do not have a proprietary drug name and where AGs count as generic even though they pay a brand CMS rebate. Consideration of brand-over-generic use pushes this figure even higher (see figure 11).

FIGURE 11: GENERIC UTILIZATION RATE

Two-Year Average: 85.6%

Generic Utilization Rate Medicaid fee-for-service (FFS) programs most often reported lower generic utilization rates than Medicaid MCO or other commercial programs due to the federal rebate’s impact on the net cost of brand drugs compared to their generic equivalents. The CMS calculation

Medicaid Forecasting

84.8%

85.7%

85.5%

85.4%

85.3%

85.9%

85.8%

86.1%

Q1

Q2

Q3

Q4

Q1

Q2

Q3

Q4

2018

FIGURE 12: MEDICAID FORECASTING

MRx Predict proactively identifies patients at risk of experiencing

their probability of being nonadherent to chronic medications in order

adverse events and forecasts future drug-cost drivers for customers.

to improve patient outcomes. Medicaid forecasting data can be found on

Two different models are available: Drug Cost Forecasting and

page 24. MRx Predict shows the overall gross trend is expected to stay

At-Risk Patient Identification. Drug Cost Forecasting provides

relatively flat from 2019, then double from 2021 to 2022 due to new,

macro-predictions on drug spend and trend, as well as the

groundbreaking therapies and specialty drugs entering the market (see

factors driving those future trends. At-Risk Patient Identification

figure 12). Rebates will continue to help offset increasing drug prices, but

proactively identifies and stratifies individual patients based on

the high cost of new specialty drugs will continue to impact the net trend.

Gross/Rx

113.36

$

45.81

Please note: COVID-19 did not impact this data, as this report covers 2018-2019 trends.

MAGELLAN RX MEDICAID PHARMACY TREND REPORT / 2020

117.57

$

121.18

$

47.77

$

2019

125.62

$

48.76

2020

134.25

$

2.2%

2.7%

2.1% $

6.9%

3.7%

3.1%

4.3%

2018

*

Net Net/Rx 3.7%

$

5

2019

50.06

$

2021

51.18

$

2022


MEDICAID FEE-FOR-SERVICE TRENDS Federal Rebate Update

Overall Drug Cost Trends

2019 saw a 1% decrease, from 55.6% to 54.6%, in the aggregate federal rebate percentage inclusive of the rebate offset amount, a sharp contrast to 2018’s 1.5% increase. This decline, driven by new specialty drugs and a growth in specialty net spend, was significantly offset by a corresponding rise in supplemental rebates — good news for states. On closer inspection, the federal rebate on traditional drugs increased 1% while the federal rebate on specialty drugs decreased 3.6%, from 48.1% to 44.5%. Considering that new-to-market drugs start with a federal rebate of 23.1% of AMP, higher utilization of newer products is pulling down the average specialty federal rebate.

2019 saw an overall increase in both gross and net cost per claim. As in 2018, the growing cost of specialty drugs was the primary contributor to the rising net trend we see in this year’s report.

FIGURE 14: GROSS COST PER CLAIM 2018

2019

Supplemental rebates as a percent of gross spend were up 0.8% year over year (4.0% to 4.8%), driven by a select group of highly utilized specialty brand drugs. Overall, total discounts, net of federal, supplemental, and ROA, were down 0.2% year over year. The average federal rebate can subdivide as either specialty and traditional drugs or brand and generic drugs (see figure 13).

% Change

4.9% 1.9%

115.54 113.35

4.5%

3.6%

117.10 113.00

119.63 114.03

118.11 113.06

3.7%

117.57 113.36

$

$

$

$

$

$

$

$

$

$

FIGURE 13: FEDERAL REBATE PERCENTAGE BY SEGMENT

Q1

Q2

Q3

Q4

Weighted Average

FIGURE 15: NET COST PER CLAIM Brand 65.4%

Specialty 48.1%

Federal Rebate* 55.6%

2018

Brand 63.7%

Traditional 60.4%

Specialty 44.5%

Federal Rebate* 54.6%

2019

% Change

7.3%

Traditional 61.4%

3.4%

4.3%

4.2% 2.3%

Generic 11.1%

Generic 11.1%

2018

2019

46.10 45.08

49.47 46.10

48.16 46.59

47.77 45.81

$

$

$

$

$

$

$

$

$

Q1 *Federal rebate as a percent of pharmacy reimbursement and net of ROA.

47.45 45.53

$

Q2

Q3

Q4

Weighted Average

2020 / MAGELLANRX.COM/TRENDREPORT

6


Traditional Drug Cost Trends

Specialty Drug Cost Trends

Traditional drug trend continued its decline for the fourth consecutive year, but, with a net cost per claim trend of just -0.4%, it is little changed since 2018. While traditional drugs still account for 98.7% of utilization, that cannot counterweight specialty drug spend’s impact on the overall drug trend.

Cost, not utilization, drove specialty trend in 2019, which saw net cost per claim increase $141.12 while utilization declined a modest 0.9%. For comparison, 2018 saw net cost per claim increase $77.43 and utilization decline -5.5%.

FIGURE 16: GROSS COST PER CLAIM

FIGURE 18: GROSS COST PER CLAIM

2018

2019

% Change

2018

6.1% 1.9%

2.1%

-0.7%

71.45 69.51

% Change

3.6%

2.8%

70.17 70.69

2019

72.80 70.26

70.68 69.21

71.26 69.92

4.7%

6.0%

3,554.12 3,354.09

4.9%

3,603.64 3,442.99

3,637.63 3,468.62

5.4%

3,735.11 3,521.60

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

Q1

Q2

Q3

Q4

Weighted Average

FIGURE 17: NET COST PER CLAIM 2018

2019

Q1

Q2

Q3

Q4

% Change

-5.4%

2018

2019

% Change 7.0%

1.1%

25.26 24.99

26.15 24.94

24.26 24.70

24.92 25.02

1,716.09 1,536.81

8.0%

7.6%

11.7%

-0.4%

-1.8%

24.06 25.44

Weighted Average

FIGURE 19: NET COST PER CLAIM

4.9%

1,742.12 1,618.43

1,800.94 1,667.74

8.6%

1,871.27 1,748.22

1,781.90 1,640.78

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

Q1

7

3,631.62 3,445.12

$

Q2

Q3

Q4

MAGELLAN RX MEDICAID PHARMACY TREND REPORT / 2020

Weighted Average

Q1

Q2

Q3

Q4

Weighted Average


MEDICAID FEE-FOR-SERVICE TRENDS Brand Drug Cost Trends

Generic Drug Cost Trends

2019 saw a year-over-year increase in both gross and net cost per claim for brand drugs, with new specialty brand drugs such as Biktarvy, Hemlibra, and Epidiolex driving trend.

2019 saw a decrease in both gross and net cost per claim for generic drugs.

FIGURE 20: GROSS COST PER CLAIM

FIGURE 22: GROSS COST PER CLAIM

2018

2019

% Change

2018

9.8%

7.5%

5.8%

2019

% Change

-5.9%

7.5%

1.8% -1.3%

7.1%

653.66 610.29

686.88 649.13

696.15 647.56

701.33 639.00

683.69 635.76

22.92 24.37

23.58 23.88

-1.0%

1.9%

24.25 23.82

23.69 23.25

23.60 23.83

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

Q1

Q2

Q3

Q4

Weighted Average

FIGURE 21: NET COST PER CLAIM 2018

2019

Q1

Q2

Q3

Q4

Weighted Average

FIGURE 23: NET COST PER CLAIM

% Change

2018

12.8%

% Change

-5.9%

8.1%

9.3%

2019

1.6%

-1.8%

10.3%

2.8%

-0.9%

11.1

%

196.55 176.92

209.95 192.14

219.06 194.19

213.99 197.97

209.55 189.96

20.21 21.47

20.77 21.16

21.41 21.06

21.32 20.74

20.92 21.11

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

Q1

Q2

Q3

Q4

Weighted Average

Q1

Q2

Q3

Q4

Weighted Average

2020 / MAGELLANRX.COM/TRENDREPORT

8


CLASS AND DRUG TRENDS In 2019, overall net cost per claim increased by $1.96, or 4.3%, from $45.81 to $47.77. In the following sections, we examine the impact of therapeutic classes and their individual drugs that contributed most to that increase.

Therapeutic Class Net Dollar Impact

Drug Net Spend Impact

Of the Top 5 classes by net spend, HIV/AIDS was the only one to also have a positive dollar impact on the Medicaid benefit (see figure 24). Conversely, stimulants and related agents were the fifth-highest-spend class but had the most negative dollar impact on the Medicaid FFS benefit, pulling the total net cost down and contributing to the negative trend in traditional net spend (see figure 25).

Some of the top traditional and specialty drugs account for large majorities of their class’s net spend. In traditional, gabapentin accounts for 43% of total net spend in neuropathic pain (see figure 26). In specialty, Mavyret accounts for more than half of total net spend in hepatitis C, at 62%, and Ibrance takes almost three quarters of spend in oncology, oral — breast, at 71% (see figure 27).

FIGURE 24: 2019 TOP 5 CLASSES INCREASING TOTAL NET SPEND BY DOLLAR IMPACT

FIGURE 26: 2019 TOP 10 TRADITIONAL DRUGS BY PERCENT OF CLASS TOTAL NET SPEND

Traditional

Specialty

Traditional

Specialty

0.42

$

0.32

42.5%

$

0.26

$

HIV/AIDS

Cystic Fibrosis, Oral

Cytokine and CAM Antagonists

0.25

$

Glucocorticoids, Inhaled

0.22

$

Bronchodilators, Beta-Agonists

FIGURE 25: 2019 TOP 5 CLASSES DECREASING TOTAL NET SPEND BY DOLLAR IMPACT Traditional Stimulants and Related Agents

Specialty

8.7%

8.7%

Latuda (Oral)

Rexulti (Oral)

Hepatitis C Agents

Analgesics, Narcotics Short

0.10

Contraceptives, Oral

0.08

$-

0.19

$-

0.41

$-

MAGELLAN RX MEDICAID PHARMACY TREND REPORT / 2020

9.2

%

Abilify Maintena (IM)

10.3%

11.1%

Vimpat Tablet (Oral)

Vraylar (Oral)

13.8%

16.3%

19%

Methylphenidate Vyvanse Invega Suboxone Film Gabapentin ER (Concerta) Capsule (Oral) Sustenna (IM) (SL) Capsule (Oral) (Oral)

FIGURE 27: 2019 TOP 10 SPECIALTY DRUGS BY PERCENT OF CLASS TOTAL NET SPEND Traditional

$-

9

38.5%

Specialty

70.9% 62.0%

Multiple Sclerosis Agents

0.06

$-

12.3%

13.4%

14.4%

Triumeq (Oral)

Advate (IV)

Hemlibra (SQ)

16.2%

16.5%

Eloctate (IV)

Genvoya (Oral)

27.8%

29.0%

Biktarvy (Oral)

Orkambi Tablet (Oral)

33.7%

Symdeko (Oral)

Mavyret (Oral)

Ibrance Capsule (Oral)


Drug Net Dollar Impact In traditional, the glucocorticoids, inhaled drug Advair Diskus had the highest net dollar impact (see figure 28). Antipsychotics had three drugs in the top 10 and had the seventh-highest impact on total net spend across all classes (see page 14). In specialty, the HIV/AIDS drug Biktarvy had the highest dollar impact at $1.19, twice the amount of the next-highest impact drug, Hemlibra (see figure 29). Conversely, the drugs decreasing the dollar impact were also from these two classes, with Genvoya impacting total net spend by $-0.25 and Adderall XR reducing total net spend by $-0.28 (see figures 30 and 31).

FIGURE 28: 2019 TOP 10 TRADITIONAL DRUGS INCREASING IN IMPACT

0.25

$

Advair Diskus (INH)

0.19

$

Vraylar (Oral)

0.18

$

Proventil HFA (INH)

0.14

$

Lidotral (Topical)

0.11

$

Concerta (Oral)

0.08

0.08

$

$

Humalog Vial (SQ)

Peg 3350 Powder Pack OTC (Oral)

FIGURE 30: 2019 TOP 10 TRADITIONAL DRUGS DECREASING IN IMPACT

Adderall XR (Oral)

0.05

$

Epinephrine 0.3 Mg (Epipen) (IM)

0.05

$

Suboxone Film (SL)

0.04

$

Abilify Invega Maintena (IM) Sustenna (IM)

0.16

$-

MethylMethylPEG 3350 phenidate ER phenidate ER Powder Pack (Concerta) (Concerta) (AG) (Oral) (Oral) (Oral)

0.10

$-

0.10

$-

0.08

$-

Humalog Pen (SQ)

0.07

$-

Strattera (Oral)

0.06

$-

Nexium (Oral)

0.06

$-

Pulmicort 0.25, 0.5 mg Respules (INH)

0.05

Lyrica Capsule (Oral)

0.05

$-

$-

Mavyret (Oral)

Triumeq (Oral)

0.28

$-

FIGURE 29: 2019 TOP 10 SPECIALTY DRUGS INCREASING IN IMPACT

FIGURE 31: 2019 TOP 10 SPECIALTY DRUGS DECREASING IN IMPACT

1.19

$

0.39

$

0.39

$

0.28

$

Biktarvy (Oral)

Hemlibra (SQ)

Epidiolex (Oral)

Symdeko (Oral)

0.23

$

Symtuza (Oral)

Genvoya (Oral)

0.16

$

$

Dupixent (SQ)

Orkambi Packet (Oral)

0.14

0.14

$

Zolgensma (IV)

0.13

0.13

$

$

Ingrezza (Oral)

Trikafta (Oral)

0.25

$-

Orkambi Tablet (Oral)

0.23

$-

Onfi Tablet (Oral)

0.16

$-

Advate (IV)

0.16

$-

Spinraza (IT)

0.15

$-

Onfi Suspension Harvoni Tablet (Oral) (Oral)

0.13

$-

0.12

$-

Descovy (Oral)

0.12

$-

0.11

$-

0.11

$-

2020 / MAGELLANRX.COM/TRENDREPORT

10


KEY THERAPEUTIC CLASSES BY NET DOLLAR IMPACT

HIV/AIDS

Cystic Fibrosis, Oral Net Dollar Impact $0.42

$33.9M

5.4%

Net Spend Trend

Total Net Spend Trend

-10.2%

Claim Volume Trend

Net Dollar Impact $0.32

17.5%

$32.5M

Net Cost Per Claim Trend

21.5%

Net Spend Trend

17.8%

Total Net Spend Trend

Claim Volume Trend

3.1%

Net Cost Per Claim Trend

Class Summary

Class Summary

HIV antiretrovirals remained the No. 1 net spend class in 2019. This class was also the No. 1 positive trend driver. With less than two years on the market, Biktarvy has quickly become the No. 1 net spend product in Medicaid. Utilization of Biktarvy drew from other Gilead products such as Genvoya, the No. 1 negative trend driver; Descovy, the No. 7 negative trend driver; products containing tenofovir disoproxil fumarate; and even Triumeq (No. 9) and Tivicay (No. 10).

This class was the No. 2 positive trend driver due to an 18% increase in utilization, moving from the No. 7 net spend class in 2018 to No. 6 in 2019.

FIGURE 33: MARKET SHARE AND NET DOLLAR IMPACT FIGURE 32: MARKET SHARE AND NET DOLLAR IMPACT Biktarvy (Oral) Tivicay (Oral) Triumeq (Oral)

Genvoya (Oral) Descovy (Oral) Other

Market Share

MARKET

Net Dollar Impact Change

4.0% 12.6%

Symdeko (Oral) Orkambi Tablet (Oral) Kalydeco Tablet (Oral) Orkambi Packet (Oral) Trikafta (Oral) Other

Biktarvy was not only the No. 1 net spend product but also the No. 1 positive trend driver. This class contained three of the Top 5 net spend products and was the No. 1 positive trend driver.

16.5%

Market Share

Net Dollar Impact Change

11.0%

10.8%

9.7%

9.5%

9.0%

0.28

$

MARKET

BRAND

Symtuza, the No. 5 positive trend driver, rose from the No. 253 net spend product in 2018 to No. 27 in 2019 despite the inclusion of a protease inhibitor instead of an integrase inhibitor.

1.19

$

8.9

%

0.14

$

55.6%

30.8%

0

-0.25

Symdeko was the No. 4 positive trend driver, advancing from the No. 23 net spend product in 2018 to No. 7 in 2019. These increases made the class the No. 2 positive trend driver in 2019.

0.13

$

0.01

$

$

52.2%

44.9%

-0.09 $-0.12 $

-0.11

$

-0.21

$

2018

11

2019

Trikafta was introduced to the market in 2019 and became the No. 76 net spend product. This pathway is similar to the other products in this class — utilization and net spend grow quickly.

20.1% 33.2%

10.9%

MARKET

CLINICAL

Dual-combination single-tablet regimens containing integrase inhibitors did not pick up significant market share, amounting to just 1% of all utilization in this class in 2019.

2019

MAGELLAN RX MEDICAID PHARMACY TREND REPORT / 2020

0

13.3% 10.7

%

17.2% 2.2

%

4.9% 2018

-0.23

$

7.7% 4.3% 2019

-0.01

$

2019

CLINICAL

Most investigational candidates in this class are not beyond phase two in clinical trials; therefore, market competition will not drive down net costs.


Cytokine and CAM Antagonists

Glucocorticoids, Inhaled Net Dollar Impact $0.26

$27.3M

36.4%

Net Spend Trend

Total Net Spend Trend

13.0%

Claim Volume Trend

Net Dollar Impact $0.25

20.7%

$27.7M

Net Cost Per Claim Trend

261.7%

Net Spend Trend

-3.2%

Total Net Spend Trend

Claim Volume Trend

273.7%

Net Cost Per Claim Trend

Class Summary

Class Summary

This class rose from the No. 10 net spend class in 2018 to No. 9 in 2019.

This class jumped from the No. 85 net spend class in 2018 to No. 28 in 2019, largely due to a temporary increase in Advair Diskus net spend. Although patent expirations on inhalers are occurring, federal rebates are still valuable as they keep brands inexpensive relative to new generic equivalents.

FIGURE 34: MARKET SHARE AND NET DOLLAR IMPACT

FIGURE 35: MARKET SHARE AND NET DOLLAR IMPACT

Humira Pen Kit (INJ) Enbrel Pen (INJ) Humira Kit (INJ) Cosentyx Pen Injecter (SQ) Otezla (Oral) Other

Market Share

Net Dollar Impact Change

MARKET

Year-over-year, TNF-alpha inhibitors account for less market share than in the previous year as more products with other mechanisms of action came to the market. In 2019, this market share was 72%.

Flovent Hfa (INH) Symbicort (INH) Advair Diskus (INH) Dulera (INH) Pulmicort 0.25, 0.5 Mg Respules (INH)

Other

Net Dollar Impact Change

Market Share

MARKET

This class experienced a 274% increase in net spend in 2019, mostly realized prior to the change in the AMP calculation that determines federal rebate amounts for products. It was the No. 4 positive trend driver.

0.02

$

0.02

$

42.5

%

14.4% 9.8% 3.7% 3.7%

25.9%

Stelara, the No. 16 positive trend driver, rose from the No. 64 net spend product in 2018 to No. 32 in 2019 despite wide non-preferred status. This trend impact came primarily from increased utilization as opposed to an increase in net spend per prescription.

41.9

11.6% 8.5%

BRAND

Advair Diskus was the No. 5 positive trend driver and rose to the No. 39 net spend product in 2019. For three quarters, it had the advantage of being under the old AMP calculation method, wherein federal rebates were substantially suppressed.

36.4% 0.25

$

19.5% 22.4%

0.23 19.1%

5.5% 3.9%

CLINICAL

28.6%

2019

31.5%

$

-0.01 2019

$

2018

BRAND

%

0

Utilization of these products grew steadily in 2019, accounting for the class ranking as the No. 3 positive trend driver. Utilization increased 13% while net spend grew by 21%.

CLINICAL

14.6% 5.7% 6.6%

5.4% 5.1%

17.6%

16.1

2018

2019

%

0.08

$

-.01 -.01

$ $

-0.05

$

0

The authorized generic for Advair Diskus accounted for only 13% of the utilization between it and the brand equivalent combined in 2019 due to the difference in their net prices. This was due to anticipation of the AMP calculation change.

2019

2020 / MAGELLANRX.COM/TRENDREPORT

12


KEY THERAPEUTIC CLASSES BY NET DOLLAR IMPACT

Bronchodilators, Beta-Agonist

Immunomodulators, Atopic Dermatitis Net Dollar Impact $0.22

$24.4M

90.8%

Net Spend Trend

Total Net Spend Trend

-4.6%

Claim Volume Trend

Net Dollar Impact $0.20

100.0%

$22.1M

Net Cost Per Claim Trend

150%

Net Spend Trend

Total Net Spend Trend

18.8%

Claim Volume Trend

110.4%

Net Cost Per Claim Trend

Class Summary

Class Summary

As in glucocorticoids, inhaled, this class experienced a brief increase in net spend prior to the implementation of the AMP calculation change that took effect Oct. 1, 2019. These classes are tied together in that fluctuations in federal rebates can have a large financial impact in these high-volume classes.

Plenty of attention is expected for this class in coming years as the market sees injectable and oral options that claim increased efficacy but come with significantly higher net costs.

FIGURE 36: MARKET SHARE AND NET DOLLAR IMPACT

FIGURE 37: MARKET SHARE AND NET DOLLAR IMPACT

ProAir HFA (INH) Proventil HFA (INH) Albuterol Neb Soln 2.5 Mg/3 Ml (INH) Albuterol Neb Soln 0.63, 1.25 Mg (INH) Ventolin HFA (INH) Other

Market Share

Net Dollar Impact Change

MARKET

Eucrisa (TOP) Protopic (TOP)

Elidel (TOP) Dupixent (SQ) Tacrolimus (TOP) Other

MARKET

This class experienced a 100% increase in net spend in 2019, mostly realized prior to the AMP calculation change that determines federal rebate amounts for products. It rose from the No. 37 net spend class in 2018 to No. 17 in 2019 and was the No. 5 positive trend driver.

Market Share

Net Dollar Impact Change

This class was the No. 6 positive trend driver and increased its net spend rank from No. 73 in 2018 to No. 29 in 2019; net spend increased 110% with an increase in utilization of 19%.

0.01

$

0.03

$

BRAND 51.8%

53.2%

0.18

$

The fact that Proventil HFA was the No. 8 positive trend driver illustrates the impact that the AMP calculation change had on net prices in Medicaid. It was the No. 41 net spend product in 2019, up from No. 796.

41.9%

44.5%

BRAND

Dupixent was the No. 9 positive trend driver, rising from the No. 136 net spend product of 2018 to No. 33 in 2019. Its utilization increased nearly 200%. 26.4%

18.8

21.9

%

%

MARKET 2.5%

18.2%

18.7

%

3.2% 2018

13

1.9% 2.4% 2.0%

0.01

$

0.03

$

5.4% 2019

In 2019, all three authorized generics for albuterol HFA brands accounted for less than 5% of all brand and generic albuterol HFA utilization due to the difference in their net prices. This was due to anticipation of the AMP calculation change.

2019

MAGELLAN RX MEDICAID PHARMACY TREND REPORT / 2020

0.16

$

36.5%

CLINICAL

Eucrisa was the leading market-share product in 2019, with a prescription total equal to that of all calcineurin formulations combined. The net spend for Eucrisa was still well under half that for Dupixent.

14.2% 5.7% 8.7%

2.2% 2.4%

2018

9.3% 2.8% 5.4% 2019

2019


Antipsychotics

Hemophilia Treatment Net Dollar Impact $0.18

$11.9M

2.8%

Net Spend Trend

-.09%

Total Net Spend Trend

Claim Volume Trend

Net Dollar Impact $0.16

3.7%

$10.5M

Net Cost Per Claim Trend

2.7%

Net Spend Trend

Total Net Spend Trend

7.7%

Claim Volume Trend

-4.7%

Net Cost Per Claim Trend

Class Summary

Class Summary

Antipsychotics remained the No. 2 net spend class in 2019. Although utilization decreased slightly, the increase in net spend per prescription more than compensated for the increased net spend relative to 2018. This class was the No. 7 positive trend driver on the strength of a 3.7% increase in net spend. In this class, utilization of longtime generics can also be a contributor to trend: The combined utilization of paliperidone and chlorpromazine was responsible for 8% of the class net spend.

As in 2018, hemophilia was the No. 3 net spend class in 2019. This class was the No. 8 positive trend driver. If the success of Hemlibra is any indication, new non-factor products to the market will continue to push net spend higher in hemophilia treatment.

FIGURE 38: MARKET SHARE AND NET DOLLAR IMPACT Quetiapine (Oral) Aripiprazole (Oral) Risperidone (Oral) Olanzapine (Oral) Latuda (Oral) Other

Market Share

23.6%

16.7%

Hemlibra (SQ) Adynovate (IV)

Advate (IV) Eloctate (IV) Idelvion (IV) Other

BRAND

Net Dollar Impact Change

Vraylar’s market share increased from 0.9% in 2018 to 1.6% in 2019 despite largely non-preferred status across states included in the analysis. It also had $0.19 impact on the drug trend, the largest contributor in the class.

Market Share

Net Dollar Impact Change

MARKET

17.4%

Latuda, Rexulti, and Vraylar utilization accounted for 8% of market share but 29% of net spend in the class.

0.27

15.2%

8.9

9.1

5.3

5.5

%

17.3%

15.8%

29.3%

2018

2019

-0.04

$

-0.04

$

2019

CLINICAL

Hemlibra, the monoclonal antibody used as prophylaxis, was the No. 8 net spend product in 2019, up from No. 74 in 2018, and the No. 2 positive trend driver.

16.3% 6.7% 4.4%

13.4% 6.6%

%

0

BRAND

0.39

$

0.02 0.05

$ $

%

29.6%

This class contained three of the top 10 net spend products in 2019: Eloctate (No. 6), Hemlibra (No. 8), and Advate (No. 9). However, Advate was also the No. 5 negative trend driver.

3.4%

5.2% %

MARKET

21.3%

23.5%

$

15.9%

FIGURE 39: MARKET SHARE AND NET DOLLAR IMPACT

-0.16

0

$

47.9%

Utilization of long-acting injectables accounted for only about 4% of market share but 39% of net spend in the class.

41.7% -0.06

$

-0.07

$

2018

2019

CLINICAL

Valoctocogene roxaparvovec is under FDA review in 2020 and could be the first gene therapy approved in this class.

2019

2020 / MAGELLANRX.COM/TRENDREPORT

14


KEY THERAPEUTIC CLASSES BY NET DOLLAR IMPACT

Anticonvulsants

Movement Disorders Net Dollar Impact $0.16

$12.1M

4.0%

Net Spend Trend

-3.9%

Total Net Spend Trend

Claim Volume Trend

Net Dollar Impact $0.16

8.2%

$17M

Net Cost Per Claim Trend

63.7%

Net Spend Trend

65.4%

Total Net Spend Trend

Claim Volume Trend

-1.0%

Net Cost Per Claim Trend

Class Summary

Class Summary

Hidden in anticonvulsants’ move from the No. 5 net spend class in 2018 to No. 4 in 2019 was the financial impact of Epidiolex. In its first full year on the market, it rocketed to the No. 16 net cost product. The net spend for anticonvulsants increased 8% from 2018 to 2019.

Utilization in this class continues to grow exponentially year-over-year, which is reflected in all net spend metrics. These drugs are commonly used to treat the side effects associated with drugs used to treat certain types of mental illness. Given the number of antipsychotic claims dispensed in Medicaid, there is plenty of room for continued growth.

FIGURE 40: SPEND AND UTILIZATION TRENDS

FIGURE 41: SPEND AND UTILIZATION TRENDS

Lamotrigine (Oral) Topiramate (Oral) Divalproex (Oral)

Clonazepam (Oral) Levetiracetam (Oral) Other

Market Share

BRAND

Net Dollar Impact Change

14.3%

14.7%

15.6%

14.5%

The generics for Onfi formulations provided significant savings — about $23 million —for states in 2019 as utilization converted to the less expensive versions. Generics for the tablet and suspension were the No. 4 and No. 8 negative trend drivers, respectively.

Ingrezza (Oral) Austedo (Oral) Tetrabenazine (Oral) Xenazine (Oral) Ingrezza Initiation Pack (Oral)

Market Share

MARKET

Net Dollar Impact Change

BRAND

11.7%

11.6%

8.7%

9.0%

7.1

7.1%

%

States did a good job of keeping utilization in brand Sabril as opposed to its generics. However, the net spend for the generics was collectively about $16 million (the No. 3 net spend product in this class) despite a prescription count that was half that of the brand utilization.

0.18

$

BRAND 57.4%

62.0%

$

21.9%

$

Ingrezza was the No. 13 positive trend driver and rose from the No. 54 net spend product in 2018 to No. 26 in 2019 despite wide non-preferred status.

0.13

CLINICAL

17.0% 42.6%

BRAND

43.1%

-0.01

$

2018

15

2019

0

Epidiolex, the No. 3 positive trend driver, fueled the class’s No. 9 positive trend driver ranking. Epidiolex was the No. 16 net cost product in 2019.

2019

MAGELLAN RX MEDICAID PHARMACY TREND REPORT / 2020

A 65% increase in utilization in 2019 led to No. 10 positive trend driver status for this class. It also rose from the No. 38 net spend class in 2018 to No. 23 in 2019.

0.04

19.9% 12.4% 5.7% 2018

3.4 2019 %

0.01

$

0.3%

-0.02

$

2019

0

Tetrabenazine saw no change in utilization between 2018 and 2019. A few states use a step requirement through this generic before accessing brands for the treatment of Huntington’s chorea with varying success.


Oncology, Oral — Hematologic

Anesthetics, Topical Net Dollar Impact $0.14

$14.0M

21.2%

Net Spend Trend

Total Net Spend Trend

-2.9%

Claim Volume Trend

Net Dollar Impact $0.13

24.8%

$13.9M

Net Cost Per Claim Trend

301.4%

Net Spend Trend

3.7%

Total Net Spend Trend

Claim Volume Trend

286.9%

Net Cost Per Claim Trend

Class Summary

Class Summary

Despite a 3% decrease in utilization, this class experienced a 25% increase in net spend that moved it from the No. 13 net spend class in 2018 to No. 10 in 2019.

Numerous PDL classes continue to be monitored for net spend impact despite a composition consisting primarily of highly utilized, inexpensive generics. Products such as Lidotral, the No. 13 positive trend driver and No. 65 net spend product in 2019, are easy to spot in this environment.

FIGURE 42: MARKET SHARE AND NET DOLLAR IMPACT Hydroxyurea (Oral) Mercaptopurine (Oral) Revlimid (Oral) Sprycel (Oral) Imatinib (Oral) Other

FIGURE 43: MARKET SHARE AND NET DOLLAR IMPACT Lidocaine Hcl Ointment (TOP) Lidocaine/Prilocaine Cream (TOP) Lidotral (TOP) Lidocaine Hcl Cream OTC (TOP) Lidocaine Hcl Cream (TOP) Other

BRAND Market Share

42.6%

Net Dollar Impact Change

Utilization of Gleevec is in the process of transitioning to imatinib as the net price for the generic becomes lower.

Market Share

Net Dollar Impact Change

BRAND

40.6%

Lidotral utilization accounted for $15 million in 2019 net spend in a class with a 2018 net spend of less than $5 million without offering a clear clinical benefit compared to existing products.

41.1%

47.7%

0.16

$

21.2% 6.9% 5.8% 3.6% 19.9%

19.0%

0.14

$

BRAND

7.2%

The transition from Imbruvica capsules to Imbruvica tablets registered a double hit on the positive trend for the class, accounting for two of the Top 10 net spend products.

5.6% 4.2% 23.4%

-0.01

$

2019

8.1%

0

-0.02

6.2% 4.9%

2019

2018

$

2018

37.0% 39.5%

0.2% 1.7%

6.5% 4.9% 2019

2.4%

-0.01

$

0

2019

2020 / MAGELLANRX.COM/TRENDREPORT

16


KEY THERAPEUTIC CLASSES BY NET DOLLAR IMPACT

Epinephrine, Self-Injected

Oncology, Oral — Breast Net Dollar Impact $0.08

$8.6M

N/A

Net Spend Trend

8.6%

Total Net Spend Trend

Claim Volume Trend

Net Dollar Impact $0.07

N/A

$86.5M

Net Cost Per Claim Trend

10.2%

Net Spend Trend

Total Net Spend Trend

-1.3%

Claim Volume Trend

11.7%

Net Cost Per Claim Trend

Class Summary

Class Summary

This class remained a source of frustration in 2019. Offering a generic that had a low net cost but was not consistently available led to increased utilization of higher-cost devices and contributed to the class status as the No. 20 positive trend driver in 2019.

There were six oncologic product divisions in the Top 31 net spend classes reported in 2019; this was the second-highest individual class and the No. 14 positive driver of net spend. It rose from the No. 15 net spend class in 2018 to No. 12 in 2019.

FIGURE 44: MARKET SHARE AND NET DOLLAR IMPACT

FIGURE 45: MARKET SHARE AND NET DOLLAR IMPACT

Epinephrine 0.3 mg (Epipen) (AG) (INJ) Epinephrine 0.15 mg (Epipen Jr) (AG) (INJ) Epinephrine 0.3 mg (Epipen) (INJ) Epinephrine 0.3 mg (Adrenaclick) (AG) (INJ) Epipen (IM) Other

Market Share

Anastrozole (Oral) Tamoxifen Citrate (Oral) Letrozole (Oral) Exemestane (Oral) Ibrance Capsule (Oral) Other

MARKET

Net Dollar Impact Change

0.02

MARKET

$

45.6%

52.5%

Market Share

Utilization of non-authorized generics for EpiPen rose from under 500 to over 20,000 in the span of a year. This utilization accounted for 34% of market share but virtually the entire $8.4 million in net spend for the class.

0.01

$

Net Dollar Impact Change

31.9%

32.6%

26.9%

24.9%

0.02

$

0.05

$

BRAND

20.1% 22.7% 0.3% 9.9% 7.7

%

0.01

$

4.2%

6.9%

7.5%

2018

2019

17

19.1%

20.1%

0.05

$

12.8% 9.8%

Generics comprised nearly 89% of utilization in this class in 2019, representing a reduction of less than 1% from 2018. Overall utilization in the class went down slightly, but net spend rose more than 10%.

6.6%

6.4%

-0.01

5.7%

5.9%

-0.01

9.8%

10.2%

2019

2018

2019

0

$

$

MAGELLAN RX MEDICAID PHARMACY TREND REPORT / 2020

2019

Ibrance dominated this class with nearly $50M in net spend as the No. 12 net spend product. However, growth in Verzenio utilization was the most significant driver of trend.


Immune Globulins

Immunomodulators, Asthma Net Dollar Impact $0.05

$5.2M

13.5%

Net Spend Trend

Total Net Spend Trend

7%

Claim Volume Trend

Net Dollar Impact $0.05

6.1%

$5.6M

Net Cost Per Claim Trend

32.8%

Net Spend Trend

13.1%

Total Net Spend Trend

Claim Volume Trend

17.4%

Net Cost Per Claim Trend

Class Summary

Class Summary

This class was the No. 15 positive trend driver in 2019 and moved up from the No. 26 net spend class in 2018 to No. 22 in 2019.

This class experienced modest increases in utilization and net spend, ranking as the No. 46 net spend class in 2019. If Dupixent had been categorized in this class instead of in immunomodulators, atopic dermatitis, this would have been a Top 20 net spend class.

FIGURE 46: MARKET SHARE AND NET DOLLAR IMPACT

FIGURE 47: MARKET SHARE AND NET DOLLAR IMPACT

Hizentra Vial (SQ) Gamunex-c (INJ) Gammagard Liquid (INJ) Privigen (IV) Cuvitru (SQ) Other

Market Share

Xolair Vial (SQ) Xolair Syringe (SQ) Nucala Vial (SQ) Fasenra Syringe (SQ) Nucala Auto-injector (SQ) Other

Net Dollar Impact Change

Market Share

Net Dollar Impact Change

0.01

$

46.7%

44.6%

MARKET 0.01

$

0.01

$

16.1%

15.1%

There was a slight uptick in utilization in 2019, evenly distributed among available products. Subcutaneously administered products continue to make up just over half the overall utilization.

BRAND

Formulation changes contributed significantly to the increased net spend in 2019, led by Xolair’s syringe — the No. 22 positive trend driver.

0.06

$

56.4%

88.8%

16.0%

0.01

$

15.2%

5.0%

7.7%

6.7%

6.3%

10.1%

10.2%

2018

2019

0.02

$

25.9%

0

0.03

$

-0.03

10.8% 8.4% 2019

2018

2.8%

5.9% 2019

$

0.7% 0.3% 2019

2020 / MAGELLANRX.COM/TRENDREPORT

18


KEY THERAPEUTIC CLASSES BY NET DOLLAR IMPACT

Antimigraine Agents, Other

PAH Agents, Oral and Inhaled Net Dollar Impact $0.05

$5.1M

267.1%

Net Spend Trend

Total Net Spend Trend

493.9%

Claim Volume Trend

Net Dollar Impact $0.04

-38.2%

$3.2M

Net Cost Per Claim Trend

6.7%

Net Spend Trend

-11.7%

Total Net Spend Trend

Claim Volume Trend

20.8%

Net Cost Per Claim Trend

Class Summary

Class Summary

As expected, prophylactic calcitonin gene-related peptide (CGRP) inhibitors caused a significant increase in this class utilization and net spend in their first full year on the market. Still, this class did not break into the Top 100 classes in net spend due to substantial discounts available to Medicaid. It was the No. 18 positive driver of trend.

This class stayed at No. 18 in net spend in 2019 but was the No. 19 positive driver of trend at the same time. This was possible due to a 21% increase in net spend owing largely to a new generic for Revatio suspension. However, there were several new generics in this class (Letairis and Tracleer) that also contributed to a lesser extent.

FIGURE 48: MARKET SHARE AND NET DOLLAR IMPACT

FIGURE 49: MARKET SHARE AND NET DOLLAR IMPACT

Aimovig (SQ) Emgality Pen (SQ) Ajovy (SQ) Cambia (Oral) Dihydroergotamine Mesylate (Nasal)

Market Share

Sildenafil Tablet (Oral) Adcirca (Oral) Letairis (Oral) Revatio Suspension (Oral) Tadalafil (Adcirca) (Oral) Other

Other

Market Share

Net Dollar Impact Change

Net Dollar Impact Change 0.01

$

CLINICAL

37.4% 0.02

$

51.7% 1.1% 3.2%

New non-triptan treatment options expected to launch in 2020 will keep a focus on the impact of this class.

0.01

$

25.6%

11.8%

9.9%

4.6% 4.2%

2018

2019

19

0.01

19.4%

0

8.4% 6.5% 1.2%

10.6% $

0.07

12.9%

10.7% 16.9%

-0.05

$

25.6%

3.3% 2019

MAGELLAN RX MEDICAID PHARMACY TREND REPORT / 2020

The use of Revatio suspension accounted for about 75% of utilization between the brand and its generic but less than 50% of the net spend between the two. Medicaid programs would have spent less money by preferring this brand over its generic equivalent.

$

13.9% 15.0%

31.5%

MARKET

32.7%

41.9%

2018

2019

2019


COPD Agents

Neuropathic Pain

Net Dollar Impact $-0.04

$-4.4M

Net Dollar Impact $-0.04

-50.5%

Net Spend Trend

-1.1%

Total Net Spend Trend

Claim Volume Trend

-50.0%

$-5.9M

Net Cost Per Claim Trend

-8.2%

Net Spend Trend

-4.5%

Total Net Spend Trend

Claim Volume Trend

-3.9%

Net Cost Per Claim Trend

Class Summary

Class Summary

In a year when negative trend drivers were less impactful than their counterparts, COPD agents had some significance. The No. 11 negative trend driver, this class experienced a decline in net spend due to increased rebate totals.

Neuropathic pain fell from the No. 11 net spend class in 2018 to No. 14 in 2019 — the No. 10 negative class driver of net spend.

FIGURE 50: MARKET SHARE AND NET DOLLAR IMPACT

FIGURE 51: MARKET SHARE AND NET DOLLAR IMPACT

Spiriva (INH) Ipratropium/Albuterol (INH) Combivent Respimat (INH) Ipratropium Nebulizer (INH) Atrovent HFA (INH) Other

Market Share

Gabapentin Capsule (Oral) Duloxetine (Cymbalta) (Oral) Gabapentin Tablet (Oral) Lyrica Capsule (Oral) Lidocaine (TOP) Other

Net Dollar Impact Change

Market Share

Net Dollar Impact Change

0 -0.01

$

39.2%

36.5

0.02

$

BRAND

The impact of Combivent Respimat’s lower net cost per prescription had the greatest financial impact in the class, but the product benefited from additional states listing it as preferred.

%

49.7%

MARKET

0.01

$

47.1%

0 -0.01

$

Although Lyrica brand utilization decreased slightly with the launch of its generic, it was actually its declining net spend that contributed most to the class’ s fall in net spend ranking.

-0.01

$

23.7%

25.5%

10.8

10.0%

-0.03

$ %

8.6% 5.2

%

6.9%

21.0%

13.9%

12.5

2018

2019

13.2%

1.7%

2.3% 10.5%

2.3% 2019

2018

-0.05

$

14.6%

5.1% 15.9%

%

19.2%

4.5% 2019

2019

2020 / MAGELLANRX.COM/TRENDREPORT

20


KEY THERAPEUTIC CLASSES BY NET DOLLAR IMPACT

Analgesics, Narcotics Long

Hypoglycemics, Insulin

Net Dollar Impact $-0.05

Net Dollar Impact $-0.05

$-5.9M

-32.4%

Net Spend Trend

-15.3%

Total Net Spend Trend

Claim Volume Trend

-20.1%

$-5.3M

Net Cost Per Claim Trend

30.8%

Net Spend Trend

-0.3%

Total Net Spend Trend

Claim Volume Trend

31.2%

Net Cost Per Claim Trend

Class Summary

Class Summary

This class served as a negative trend driver based on the 15.3% reduction in prescriptions and the 20.1% reduction in net spend.

This class remains at the bottom of the rankings according to net spend yet continues to decline in overall financial impact to Medicaid, ranking as the No. 6 negative driver of trend in 2019.

FIGURE 52: MARKET SHARE AND NET DOLLAR IMPACT

FIGURE 53: MARKET SHARE AND NET DOLLAR IMPACT

Morphine ER Tablet (Oral) Fentanyl (TD) Oxycontin (Oral) Methadone Tablet (Oral) Methadone (Oral) Other

Market Share

Lantus Solostar Pen (SQ) Novolog Pen (SQ) Lantus Vial (SQ) Humalog Vial (SQ) Levemir Pens (SQ) Other

Net Dollar Impact Change

Market Share

Net Dollar Impact Change

0 -0.01

$

27.5%

30.1%

-0.01

$

14.8%

17.0%

CLINICAL

The continued trend away from opioid analgesic utilization resulted in No. 7 negative class trend driver status for this class. Utilization fell 15% in 2019 after a double-digit decrease in 2018, as well.

22.9%

MARKET

25.5% 0.08

$

10.5% 11.8

%

10.8% 9.8%

0 -0.02

$

13.8

%

-0.01

$

14.8% 8.2% 8.9% 2.1%

-0.02

2018

21

9.8%

9.2%

9.2

34.9%

34.9%

2018

2019

%

-0.01 -0.01

$ $

7.6% $

27.1%

10.7%

-0.08

$

28.1

%

2019

2019

MAGELLAN RX MEDICAID PHARMACY TREND REPORT / 2020

2019

As expected, authorized generics and biosimilars again did not make an impact in utilization in this class due to their high relative net cost compared to reference brands. Less than 2% of utilization was in these product types.


Multiple Sclerosis Agents

Analgesics, Narcotics Short

Net Dollar Impact $-0.06

Net Dollar Impact $-0.10

$-7.8M

-14.9%

Net Spend Trend

Total Net Spend Trend

-12.6%

Claim Volume Trend

-2.5%

$-12.0M

Net Cost Per Claim Trend

-18.9%

Net Spend Trend

-17.8%

Total Net Spend Trend

Claim Volume Trend

-1.3%

Net Cost Per Claim Trend

Class Summary

Class Summary

A 13% reduction in utilization was primarily responsible for this class’ status as the No. 5 negative trend driver in 2019. There were slight increases in oral therapies and small declines in injectable ones.

This class had the third-most negative trend due to a 17.8% decrease in utilization and an 18.9% decrease in net spend.

FIGURE 54: MARKET SHARE AND NET DOLLAR IMPACT

FIGURE 55: MARKET SHARE AND NET DOLLAR IMPACT

Tecfidera (Oral) Gilenya (Oral) Aubagio (Oral) Copaxone 40 mg/ml (SQ) Copaxone 20 mg/ml (SQ) Other

Hydrocodone/APAP (Oral) Oxycodone/APAP (Oral) Oxycodone (Oral) Tramadol (Oral) APAP/Codeine (Oral) Other

BRAND Market Share

17.7%

Net Dollar Impact Change

18.9%

Increased rebate obligation for Copaxone 40 mg/ml injection was the most significant net price change in this class. Even so, this only rated as the No. 43 negative trend driver.

0.01 .0.02

0

$

-0.01

12.4%

11.9%

12.4%

12.8%

11.8%

11.8%

10.4%

Net Dollar Impact Change

$

$

11.9%

Market Share

37.2%

0

36.6%

-0.01

$

-0.04

$

-0.01

$

-0.04

2018

34.1

%

2019

20.9%

15.6%

16.6%

15.4%

15.2%

%

4.9 5.9%

4.8 5.9%

2018

2019

CLINICAL $

33.9%

21.0%

2019

New product launches for Mavenclad and Mayzent did not make an impact in a market with sufficient oral options for treatment.

CLINICAL

The continued trend away from opioid analgesic utilization resulted in No. 3 negative class trend driver status for this class. Utilization fell 18% in 2019 after a double-digit decrease in 2018, as well.

-0.04

$

-0.04

$

%

-0.01

$

2019

2020 / MAGELLANRX.COM/TRENDREPORT

22


KEY THERAPEUTIC CLASSES BY NET DOLLAR IMPACT

Hepatitis C Agents

Stimulants and Related Agents Net Dollar Impact $-0.41

Net Dollar Impact $-0.19

$-24.7M

-14.8%

Net Spend Trend

-1.8%

Total Net Spend Trend

Claim Volume Trend

-13.2%

$-51.2M

Net Cost Per Claim Trend

Net Spend Trend

-16.5%

Total Net Spend Trend

-2.8%

Claim Volume Trend

-14.1%

Net Cost Per Claim Trend

Class Summary

Class Summary

This class dropped in the net spend rankings from No. 6 in 2018 to No. 7 in 2019. Utilization of salvage treatments remained low, speaking to the high real-world effectiveness of the oral treatment options.

Despite its status as the No. 1 negative trend driver among PDL classes, stimulants and related agents was still the No. 5 net spend class in 2019. Net spend fell over 14% between 2018 and 2019, largely due to utilization movement between brand and generic equivalents. As discussed on page 4, federal rebate values were significantly changed by the removal of authorized generics from the blended AMP calculation upon which federal rebates are based. Increases in Adderall XR and Concerta federal rebates following the revised calculation resulted in net prices to states that were far more attractive than that of their generic equivalents.

FIGURE 56: MARKET SHARE AND NET DOLLAR IMPACT Mavyret (Oral) Epclusa (Oral) Harvoni (Oral) Sofosbuvir/velpatasvir (AG) (Oral) Vosevi (Oral) Other Market Share

BRAND

Net Dollar Impact Change 0.05

$

0.01

$

49.8%

0

The authorized generic for Epclusa (and, to a lesser extent, Harvoni) ranked a modest No. 207 in 2019. The manufacturer launched its own authorized generic as a mechanism to decrease reimbursement costs. However, net prices in Medicaid were such that the appeal of the authorized generic did not extend throughout this market.

51.3% -0.11

$

MARKET

Mavyret was the No. 11 negative trend driver and its net spend rank fell from No. 2 in 2018 to No. 3 in 2019. Utilization was relatively unchanged. 34.3%

12.9%

2018

23

Vyvanse Capsule (Oral) Amphetamine Salt Combo (Oral) Guanfacine ER (Oral) Adderall XR (Oral) Focalin XR (Oral) Market Share

2.2%

5.1% 3.7% 4.0% 2019

-0.12

$

0.02

$

19.3%

13.3%

13.4%

9.7%

10.6%

13.0%

10.1%

1.6%

-0.02 $-0.01 2019 $

MAGELLAN RX MEDICAID PHARMACY TREND REPORT / 2020

-0.01

$

BRAND -0.28

$

-0.04

$

36.3%

39.0% -0.10

$

2018

0

Concerta was the No. 15 positive trend driver and rose to the No. 110 net spend product in 2019, up from No. 7,300 in 2018. Its generics, authorized and non-authorized, were the No. 13 and No. 14 negative trend drivers, respectively, and together would have been the No. 4 negative trend driver.

Adderall XR was the No. 1 negative trend driver and fell from the No. 13 net spend product in 2018 to No. 56 in 2019. The class was also the No. 1 negative trend driver, as net spend fell 14% in 2019.

7.6%

MARKET

Utilization did not change appreciably year-over-year; a lower net spend (-13%) designated this class the No. 2 negative trend driver.

BRAND Other

Net Dollar Impact Change

19.8%

7.9%

28.7%

6.4%

FIGURE 57: MARKET SHARE AND NET DOLLAR IMPACT

2019

2019

MARKET

The impact of the AMP calculation change, effective Oct. 1, 2019, will continue to be felt throughout 2020 and beyond for some key products, leading to increased market share shifts from generics to their brand equivalents.


PIPELINE AND FORECASTING Keep on Your Radar

Key Conditions Forecast

Notable agents that are further from approval have been identified in Figure 58. These products have the potential for significant clinical and financial impact. Their development status is being tracked on the MRx Pipeline radar. These pipeline products, their respective class or proposed indication, and an estimated financial forecast for the year 2024 are displayed. The financials are projected total annual U.S. sales, reported in millions. 2

With a steady increase in the pipeline, many key conditions, notably those with generic introductions or specialized management strategies, such as pain conditions, hepatitis C, and MS, will see steady annual increases in trend over the next three years (see figure 59).

FIGURE 59: KEY CONDITIONS FORECAST 2020

FIGURE 58: KEEP ON YOUR RADAR 2

2021

2022

20%

voclosporin

aducanumab

$649

$940

Immunology

17%

Neurology

remdesivir COVID-19

12% 12%

relugolix

casimersen

Neurology/Gene Therapy

$187

$578

9%

8%

5%

Anti-Clotting Therapy

4

%

-9%

3%

$366

Women's Health/ Oncology

11%

-3%

9%

betibeglogene autotemcel (Zynteglo)

Hematology/Gene Therapy

$1,190

17%

1%

Asthma/COPD

Attention DeficitHyperactivity Disorder

Autoimmune: Anti-inflammatory

Depression

efgartigimod

mRNA-1273 vaccine COVID-19

Immunosuppressants

$2,859

$727

lonapegsomatropin

elivaldogene tavalentivec (Lenti-D)

Endocrine

$589

Neurology/Gene Therapy

$42

2% 10%

10% 6

%

lenadogene nolparvovec (GS010) Ophthalmology/ Gene Therapy

$39

-5%

inclisiran

Cardiovascular

ipatasertib

For more detailed information on the pipeline, please see the latest MRx Pipeline Report on our website.3

4%

3%

3%

-9% -13%

Diabetes

$510

7%

-10%

$693

Oncology

10%

-1%

7%

HIV/AIDS

Hypertension

Multiple Sclerosis

Oncology

drug names appear in ď‚Ť Specialty magenta throughout the publication.

2 This unique watch list displays products with the potential for significant clinical and financial impact. These pipeline products, their respective class or proposed indication, and an estimated financial forecast for the year 2024 are displayed. The financials are projected total annual U.S. sales, reported in millions. 3 MRx Pipeline Report. https://issuu.com/magellanrx/docs/mrx_pipeline_jul_2020_mrx1119_0720?fr=sNmViZjE3MzM0OTQ accessed July 2020.

2020 / MAGELLANRX.COM/TRENDREPORT

24


METHODOLOGY The Magellan Rx Medicaid Trend Report focused exclusively on Medicaid FFS drug spend and does not include managed care organization (MCO) utilization. It provides a comprehensive year-over-year analysis of Medicaid FFS pharmacy claims data on a cost-per-claim basis.

» T he report trends are based on gross and net cost per claim and compare 2018 calendar year data to 2019 calendar year data. » T he data set used in this evaluation contains more than 111 million claims with a gross cost of $13 billion and a net cost of $5.3 billion. » D  ata was obtained from 26 Medicaid FFS clients across the country from which two years of complete FFS data are available. Claims data used in this report is publicly available on the CMS website: https://www.medicaid.gov/medicaid/prescriptiondrugs/state-drug-utilization-data/index.html.

» A  s in commercial plans, traditional and specialty drug trends are not immune to manufacturer price actions at the gross cost level; however, the increase at the net cost level is somewhat mitigated by supplemental rebates (where applicable) and the CPI-U penalty component of the federal rebate. » T o achieve the highest level of accuracy for the Medicaid FFS space, this report again incorporates the CMS federal rebate data for both 2018 and 2019. Federal rebate data at the drug level is confidential and protected by federal law under the Social Security Act at 42 U.S.C. 1396r-8 (b)(3)(d). Therefore, this report does not disclose net cost pricing information on a per-drug basis.

DOWNLOAD OUR BONUS

District of Columbia

COVID-19 Edition MRx Pipeline Report today! May 2020

MRx PIPELINE MRx customer data used in analysis

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M AGELL ANR X .COM

MAGELLAN RX MEDICAID PHARMACY TREND REPORT / 2020

Bonus COVID-19 Edition

For a downloadable version (PDF) of this report or any of our other trend reports, please visit magellanrx.com.


GLOSSARY ACA.................................................................................................................................................Affordable Care Act

INH....................................................................................................................................................inhaled/inhalation

AG..................................................................................................................................................... authorized generic

INJ......................................................................................................................................................................... injectable

AMP............................................................................................................................. average manufacturer price

IV....................................................................................................................................................................... intravenous

ASP...................................................................................................................................................average sales price

LOB..........................................................................................................................................................line of business

AWP.....................................................................................................................................average wholesale price

MACPAC............................................................ Medicaid and CHIP Payment and Access Commission

CGRP..................................................................................................................calcitonin gene-related peptide

MCO.............................................................................................................................. managed care organization

CMS.............................................................................................Centers for Medicare & Medicaid Services

P&T...............................................................................................................................pharmacy and therapeutics

COPD................................................................................................ chronic obstructive pulmonary disease

PDL................................................................................................................................................... Preferred Drug List

CPI-U................................................................................Consumer Price Index for All Urban Consumers

ROA............................................................................................................................................. rebate offset amount

DUR.........................................................................................................................................drug utilization review

SOS............................................................................................................................................................. site of service

ER..........................................................................................................................................................extended release

SQ................................................................................................................................................................ subcutaneous

FDA............................................................................................................... U.S. Food and Drug Administration

TD.....................................................................................................................................................................transdermal

FFS............................................................................................................................................................. fee-for-service

TOP...............................................................................................................................................................................topical

FMAP...................................................................................................federal medical assistance percentage

WAC................................................................................................................................wholesale acquisition cost

GDR.......................................................................................................................................generic dispensing rate

XR ........................................................................................................................................................extended release

HHS..................................................................................U.S. Department of Health and Human Services IM..................................................................................................................................................................intramuscular 2020 / MAGELLANRX.COM/TRENDREPORT

26


Profile for Magellan Rx Management

Medicaid Pharmacy Trend Report - 2020  

Medicaid Pharmacy Trend Report - 2020  

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