Glen Stettin, a senior Express Scripts executive, said an estimated 70 million Americans have high cholesterol.
He estimates fewer than 10 percent of them should qualify for Praluent, based on restrictions from the Food and Drug Administration, which limited the drug’s use mostly to patients with a hereditary form of high cholesterol and people with cardiovascular disease.
“The big worry for our clients, given the cost of these drugs [$1,120 per 28-day treatment cycle — or about $14,600 per year], is whether they will be used beyond ways they were tested,” Stettin said.
Before getting their prescriptions filled, patients in Express Scripts plans will be asked for documentation of their diagnosis, their cholesterol levels, diet and maximum tolerated statin therapy, Stettin said.
Last Monday was the deadline for the public to submit comments in response to the Center for Medicare and Medicaid Service’s (“CMS”) request for public input on what to do with the HIPAA health plan identifier (“HPID”). HHS rolled out this identifier and then just before the compliance date last Fall pulled it back as unnecessary for HIPAA transactions. To get a flavor for the public comments here, are links to comments submitted by the American Hospital Association and the American Benefits Council. Both throw cold water on the HPID but the AHA is perfectly willing to let CMS use the HPID in connection with the HIPAA operating rule certification requirement that the ACA imposes on health plans. The AMA urges CMS to pull that proposed rule out of the deep freeze.
A few weeks ago, the FEHBlog noted that the AMA and CMS had reached agreement on a rather vague transition plan for implementing the fiendishly complex ICD-10 coding system for electronic claims on October 1, 2015. CMS issued FAQs on that transition plan earlier this week. The FAQs confirm that FEHB plans and other commercial payers are not obligated to implement the CMS transition plan. The FAQs also provide more details on acceptable transition plan coding for the benefit of Medicare providers. iHealthbeat has a more detailed overview of the FAQs here.
Finally, the FEHBlog noticed today that the OPM Inspector General has posted his most recent semi-annual report to Congress and management’s response on his website. That report is always interesting reading.