With the public debate about prescription drug prices playing out in the press, in Congress, and among regulators, policymakers are focusing on the role of pharmacy benefit managers (PBMs) in addressing drug costs.

Operating under contract with health plan sponsors – insurers and self-funded employer plans alike – PBMs work to lower prescription drug costs for patients. In addition to their role negotiating lower drug costs with manufacturers and pharmacies, PBMs also monitor the drug development pipeline for new therapies, and through their affiliated mail service and specialty pharmacies, provide safe, convenient, and less expensive home-delivered medications for patients. During the COVID-19 pandemic, PBMs facilitated ready access to mail delivery of needed medications for those trying to stay safe, encouraged and facilitated health plan enrollee COVID vaccination, and supported efforts to identify and help address health care disparities.

PBM Policy Forum 2021 Agenda

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Digital Therapeutics: Pharmacy Care Innovation and Implications for Policy

Susan Cantrell, Chief Executive Officer, Academy of Managed Care Pharmacy

Megan Coder, Executive Director, Digital Therapeutics Alliance

Laura Topor, President, Granada Health and Former NCPDP Trustee

Moderator: Claire Wulf Winiarek, Vice President of Policy, PCMA

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In response to the disruption accelerated by the global coronavirus pandemic and changing consumer preferences, digital technology continues to transform the way health care is practiced and delivered. Innovations like prescription digital therapeutics (DTx) are forging ahead to complement traditional pharmaceutical and other health care approaches and advance patient care. This webinar will provide an introduction and review of DTx, how the DTx product and coverage landscape is evolving, contemporary regulatory and standard issues relating to coverage and payment of DTx, and emerging policy and regulatory questions.

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Value-based Arrangement Collaboration: Using Real World Data and Comparative Effectiveness to Promote Value-based Purchasing

Tom Peddicord, Head National Accounts Population, Health MSL Team, U.S. Pharma HE&OR and Medical Access, Novartis Pharmaceuticals Corp

Brett Sahli, Senior Director, Value and Outcomes, Prime Therapeutics

Moderator: Ian Spatz, Senior Advisor, Manatt Health, Manatt, Phelps & Phillips

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During this session, the panelists will share how PBMs are working with manufacturers and others in the supply chain to leverage real world evidence in value-based purchasing of, or outcomes-based contracting for, prescription drugs. This session will discuss the origins of successful value-based arrangements (VBA), factors for success, how the arrangement progresses to a “2.0” phase, and opportunities for greater alignment on value and patient outcomes through the advancement of VBAs.

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Achieving Widespread Access to COVID-19 Vaccines

Dr. Sree Chaguturu, Senior Vice President & Chief Medical Officer, CVS Caremark

Dr. Elena Rios, President and Chief Executive Officer, National Hispanic Medical Association

Moderator: Claire Wulf Winiarek, Vice President of Policy, PCMA

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Although the COVID-19 vaccine rollout has had a successful start, major health inequities still exist in vaccine access for underserved communities and underrepresented minorities. Between 2 and 3 million Americans are being vaccinated a day, but disproportionately fewer of those vaccinated are in communities of color and other underrepresented communities. Discuss the unique social determinants of why these inequities exist, why it’s important to reframe COVID-19 vaccination campaigns for specific communities, and how health care stakeholders, including physicians and PBMs, are working to educate underserved populations on the safety and efficacy of COVID-19 vaccines.

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Future of Prescription Drugs: Addressing the Hope and High Costs Gene Therapy, Curatives, and Ultra Orphans

Matt Perlberg, Senior Vice President, Supply Chain, Express Scripts

Moderator: Ian Spatz, Senior Advisor, Manatt Health, Manatt, Phelps & Phillips

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Biopharmaceutical innovation continues to deliver groundbreaking rare disease, curative, and personalized gene therapies to meet unmet patient medical needs. While these new advancements, such as orphan and gene therapies, offer new hope, they also represent a significant challenge of affordability. The health care system will require additional tools and collaboration to ensure appropriate therapy access and predictable affordability. This session will discuss industry trends and priorities, areas of payment and pharmaceutical care management innovation, and opportunities to find common ground to address these unique challenges across the health care ecosystem – essential  to maintaining and supporting biopharmaceutical innovation and access in the future.

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Reshaping Drug Coverage: How States Use Medicaid Waivers to Impact Drug Coverage

Ross Margulies, Partner, Foley Hoag

Matt Salo, Executive Director, National Association of Medicaid Directors

Moderator: Debjani Mukherjee, Senior Director, Regulatory Affairs, PCMA

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In 2019, specialty drugs accounted for 48.5 percent of net cost in Medicaid while making up just 1.3 percent of utilization. Unit cost – not utilization, which fell – drove Medicaid specialty trend, with net cost per claim increasing by $141.12. States and their Medicaid programs are facing stark challenges when it comes to the affordability of these high-cost drugs. This session will review the prior administration’s efforts related to Medicaid waivers, specifically the waiver requested by the state of Tennessee, which included a closed formulary, and the potential mechanisms to innovate Medicaid prescription drug coverage through additional commercial-like tools.

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Medicare Part D: Partnering to Advance Health Care Outcomes

Bethanie Stein, President of PBM Services, Humana Inc.

Moderator: Ian Spatz, Senior Advisor, Manatt Health, Manatt, Phelps & Phillips

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Since the launch of Medicare’s prescription drug benefit in 2006, Part D plan sponsors have been central to advancing health care outcomes for Medicare beneficiaries. This session will focus on the Part D program, highlighting targeted and comprehensive clinical care programs offered by plan sponsors, and innovative programs developed in partnership with the Center for Medicare and Medicaid Innovation (CMMI) such as the Senior Savings Demonstration Model aimed at improving medication adherence through capping beneficiary out-of-pocket costs for insulin.

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Progress on Expanded Biosimilar Availability

Deedrea Grein, Senior Vice President, Product, OptumRx

Michael Zeglinski, Senior Vice President and Chief Executive Officer, Specialty Infusion Pharmacy, OptumRx

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Biosimilar approval and marketing of products in the United States had been proceeding at a slower pace than desired by many stakeholders but has picked up significantly. Our speakers will discuss the importance of competition for biologics and biosimilars “coming of age” in the United States, as well as recent and expected future developments in the market. Additionally they will explain how PBMs are supporting biosimilar adoption, the movement from medical benefit to drug benefit for coverage of biosimilars, how payers are working with PBMs to advance access to biosimilars, and the role of patient and provider education.

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Collaborating to Promote Specialty Drug Access and Improved Health Outcomes for Patients

Adam Kautzner, Chief Pharma Trade Relations Officer, Express Scripts

Gary Loeber, Executive Vice President of Pharmaceutical Contracting and Purchasing, CVS

Patrick Moss, Vice President of Specialty Distribution & Payer Access, Sarepta Therapeutics

Jen Norton, Vice President and Head of U.S. Value & Access, Amgen

Moderator: Ian Spatz, Senior Advisor, Manatt Health, Manatt, Phelps & Phillips

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The overall drug pipeline disproportionately reflects specialty drugs, which showcase promising pharmaceutical innovation for patients, but often come with high costs. Value based arrangements (VBA) are gaining traction in the market thanks to a number of factors including aligned incentives and access to better data. This session features a panel discussion on why the oncology and rare disease categories are ideal for VBAs, and how PBMs and biopharmaceutical companies are innovating to structure collaborative arrangements that support patient access, affordability, and care management to improved health outcomes.

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Improving Member Experience Through Digital Provider Connections

Jacquelyn Vondrak, Staff Vice President of Clinical Pharmacy Services, IngenioRx

Moderator: Ian Spatz, Senior Advisor, Manatt Health, Manatt, Phelps & Phillips

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When PBM’s and providers are digitally connected, patient and provider abrasion are reduced. Giving providers actionable information within their EMR workflow is paramount to effectively partnering with them to close gaps in care. IngenioRx uses digital functionality with providers for pharmacy insights, electronic prescribing, real time pharmacy benefits and electronic prior authorization to help reduce disruption for both the provider and patient member. This session will highlight how PBMs like IngenioRx are leveraging technology to provide improved clinical care to patients, and a look into the adoption and utilization of these technologies.