American Journal of Managed Care: UMass Medical School partners with Massachusetts Medicaid to design CAR-T carve out

November 01, 2018

A unique approach to covering the costs of, and ensuring access to, expensive life-saving chimeric antigen receptor (CAR-T) therapies developed by the Massachusetts Medicaid program, MassHealth, in partnership with UMass Medical School is featured in a recent American Journal of Managed Care article. The payment solution was highlighted in a UMass Medical School presentation at the Academy of Managed Care Pharmacy’s AMCP Nexus 2018.

The new Carve-Out initiative through the MassHealth pharmacy benefit tackles the fact that CAR-T treatments have a higher list price than agreed upon provider reimbursement rates and have the potential to distort the rates. The policy means providers can bill MassHealth separately for CAR-T treatment and also bill for the associated costs of hospitalization. If the therapy is not effective at 30 days, and the treatment facility has an outcomes-based agreement in place, MassHealth does not pay for the Carve-Out drug. In this instance, MassHealth would only pay for services associated with the treatment course.

The Carve-Out was developed in late 2017 — shortly after the approvals of CAR-T treatments Kymriah® (tisagenlecleucel) and Yescarta® (axicabtagene ciloleucel) — became effective in March 2018, and was approved by the Centers for Medicare and Medicaid Services in June 2018. To compliment the CAR-T Carve-Out, UMass Medical School’s clinical pharmacy team developed a Monitoring Program to track patient outcomes.

Stephanie Tran, PharmD, a clinical consultant pharmacist at UMass Medical School, and Therese Mulvey, MD, MassHealth Drug Utilization Review Board member, discussed the Carve-Out as part of their Oct. 24 AMCP Nexus presentation, The CAR-T Carve Out: Reevaluating CAR-T Reimbursement and Long-Term Outcomes. The presentation focused on new CAR-T therapies to treat acute lymphoblastic leukemia and diffuse large B-cell lymphoma, as well as the affordability of and access to these therapies.

“These are drugs that are very expensive, but if the patients have a response, and the responses are durable, the folks won’t require additional treatment,” said Mulvey, who is also director of Quality Safety and Value at the Massachusetts General Hospital Cancer Center and Affiliate Network.

The pair discussed new promising therapies and their high costs. These treatments are often the last options for patients and can have extremely positive results. For example, Yescarta® (axicabtagene ciloleucel) has been approved to treat diffuse large B-cell lymphoma at a cost of $373,000 for the product alone. Additional ancillary costs are estimated to be $33,000 per patient, although media reports suggest figures up to 10 times that amount.

Mulvey said payers and policymakers should come up with ways to increase and ensure access to life-changing CAR-T treatments for those who live in remote areas or cannot afford the treatment. Tran highlighted how MassHealth provided access to CAR-T therapies and carved out these therapies from the medical benefit to be managed under the pharmacy benefit.


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