BLOG: Game on: Cequa jumps into Medicare Part D
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Ladies and gentlemen, we have ourselves a contest here!
It’s game on for immunomodulators in the Medicare Part D space. For more than 15 years, it’s been a one-horse race. You could treat your patients with dry eye disease (DED) with any kind of immunomodulator as long as it was Restasis. Not that this is a bad thing, mind you. Restasis is a fantastic medication. It is not an exaggeration to say that the entire pharma space in DED exists because of Allergan and Restasis. Indeed, in the early 2000s when pricing was straightforward and easy to understand, the absence of a competitor for Restasis was not an issue.
In today’s world where prices are set in smoke-filled back rooms by pharmacy benefit managers/pharma cabals, the only thing that will bring some sense to the market is competition.
Entering the ring to make this real is the edgy newcomer, Sun Pharma. Thwarted as completely as Shire/Takeda/Novartis when it came to getting a spot on the various Part D carrier formularies, the Sun team did a deep dive into the morass of Medicare regulations and discovered that Medicare-eligible patients can “opt out” of Medicare coverage for any chronically prescribed medication. By attesting to their intention to not seek Medicare coverage, a patient can participate in the kind of cash-pay programs we have seen in the under-65 commercial market. To qualify on the pharma side, a company cannot price their medication low enough to invoke the “inducement to treat” threshold. If you have been prescribing Cequa (or AzaSite, among others) in the commercial space, this will all sound familiar.
Here’s how it works (disclaimer: this is my understanding of how it works)*: You prescribe Cequa and send the script to PARx/CoverMyMeds. It is then sent through ScriptHero where all insurance coverage is vetted and any prior authorization is performed. When you come up snake eyes, as you always do, an email is generated so that your patient can decline Medicare coverage for the prescription. Some of your patients will misunderstand this and think you are asking them to drop out of Medicare entirely; you should expect to explain that this is not the case. Once your patient attests that they will not ask Medicare to pay for Cequa, you are in the game.
Sun is charging $89 to $95 for a 1-month supply (one tray, 60 vials) of Cequa. This is more than the typical $40 co-pay for Restasis, but because it is no longer covered by Medicare, the $89 to $95 is neither subject to a deductible (and cannot be applied to the deductible), nor is it subject to the madness that is the “donut hole.” This is a first dollar price for any and all scripts that are filled. All of our age-old immunomodulator “math” applies; three doses in both eyes per vial make this a de facto 3-month supply at approximately $30 per month. Make your Sun rep explain this to you and the person who gets meds covered for your patients.
We finally have some competition in the Part D space in DED. Let’s see if Novartis comes up with a bid for Xiidra. Who knows, maybe one of the steroid manufacturers will follow suit. It’s game on for dry eye in Medicare.
*I’m not kidding. This is just my understanding of how this works. My description is not the final word. Your Sun rep will have the official explanation. As the first guy to talk about this, I reserve the right to be confused about the details.
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