There isn’t much insurance coverage for digital prescription therapies these days, but Jayne Hornung says Medicare coverage would open that door — and maybe the floodgates.
“I see it as where specialty pharmacy was 25 years ago,” Hornung, clinical director, pharmacy, for MMIT, a market access company in Yardley, Pennsylvania, said in an interview ahead of the Asembia Summit. Specialty Pharmacy 2022 in Las Vegas where she leads a session on digital therapeutics. “There weren’t a thousand specialized pharmacies because there were no specialized medicines. But now there are a thousand specialty drugs, and we have a thousand specialty pharmacies, and we have tons of policies covering specialty pharmacies because of that.
Hornung stressed that passage of the digital prescription therapy access legislation, which would extend Medicare coverage to apps, was critical. The legislation is sponsored by Representatives Mike Thompson, a Democrat from California, and David McKinley, a Republican from West Virginia, in the House and by Sens. Jeanne Shaheen, a Democrat from New Hampshire, and Shelley Moore Capito, a Republican from West Virginia, in the Senate.
With Medicare coverage, digital prescription therapies will begin to be integrated into clam payment systems and electronic medical records: “Once Medicare says it’s a thing, we have to deal with it,” said said Hornung.
Hornung’s projection is a not-if-but-when projection: “Digital therapies are coming and as an industry we need to think about how we are going to handle them.
Hornung was careful to distinguish between the many wellness apps and digital prescription therapies, of which she said there were only nine, that are designed to treat an illness and have research for safeguard their safety and effectiveness. It’s a distinction that Pear Therapeutics and some of the other developers of digital prescription therapy emphasize, particularly in the context of insurance coverage.
Hornung planned to share at the Asembia meeting some of the results of a recent survey conducted by MMIT of 15-20 payers (a group including pharmacy benefit managers, large regional payers and large national payers) on their coverage and their digital therapeutic policies. .
“The coverage landscape is very thin,” Hornung said in his interview with Managed Health Framework.® “About 25% of payers actually thought about saying, yes, we cover that, or no, we don’t cover that.” Many payers are now making decisions on a case-by-case basis and denying the majority of requests, she said.
Once the question of coverage is resolved, there is also the question of whether digital prescription therapies will be covered by the pharmaceutical or medical benefit. Hornung said that “bringing it through the pharmacy benefit is the industry’s destination” because of the ordering infrastructure: people would have the ability to order additional months of access to an app in a way to now be able to obtain prescriptions for a new supply of a drug.
“I think today getting reimbursed by either (the pharmacy or the medical benefit) would be a step in the right direction,” Hornung said.
Some pointed to the coverage of continuous glucometers as a precursor. Private payers cover them on both, Hornung said. Medicare covers monitors on the drug benefit but lancets and test strips on the medical benefit. “It’s a pain in the neck,” Hornung said.