Medicare Coverage Crucial to Prescription Digital Therapeutics: 2022 Asembia Specialty Pharmacy Summit

There isn’t much insurance coverage of prescription digital therapeutics these days, but Jayne Hornung says Medicare coverage would open that door – and possibly the floodgates.

“I see it as where specialty pharmacy was 25 years ago,” said Hornung, chief clinical officer, pharmacy, for MMIT, a market access company in Yardley, Pennsylvania, in an interview before the 2022 Asembia Specialty Pharmacy Summit in Las Vegas where she is a leading a session on digital therapeutics. “There weren’t a thousand specialty pharmacies out there because there weren’t any specialty drugs. 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.”

Jayne Hornung

Hornung pointed to passage of Access to Prescription Digital Therapeutics legislation, which would extend Medicare coverage to the apps, as critical. The legislation is sponsored by Reps. Mike Thompson, a California Democrat, and David McKinley, a West Virginia Republican, in the House and by Sens. Jeanne Shaheen, a New Hampshire Democrat, and Shelley Moore Capito, a West Virginia Republican, in the Senate.

With Medicare coverage, prescription digital therapeutics will start to get incorporated into systems for paying clams and into electronic medical records: “Once Medicare says it is a thing, we have to address this thing,” Hornung said.

Hornung’s projection is a not-if-but-when one: “Digital therapeutics are coming and as an industry we have to think about how we are going to handle them.

Hornung was careful to draw a distinction between the many wellness apps and prescription digital therapeutics, of which she said there are only nine, that are designed to treat a disease and have some research to back up their safety and efficacy. This a distinction that Pear Therapeutics and some of the other developers of the prescription digital therapeutics emphasize, especially in context of insurance coverage.

Hornung was planning to share at the Asembia meeting some of the results of a recent survey that MMIT conducted of 15-20 payers (a group that included pharmacy benefit managers, large regional payers, and large national payers) about their digital therapeutics coverage and policies.

“The landscape of coverage is very slim,” Hornung said in her interview with Managed Healthcare Executive.® “About 25% of payers have actually thought to the point where they, say, yes we cover this, or no, we don’t cover this.” Many payers currently make decisions on a case-by-case basis, and they deny a majority of requests, she said.

Once the coverage issue gets ironed, there is also the question whether the prescription digital therapeutics will be covered on the pharmacy benefit or the medical one. Hornung said “putting it through the pharmacy benefit is where the industry is going” because of the ordering infrastructure: people would have the ability to order additional months of access to an app in way that they can now get prescriptions for a new supply of a medication.

“I think, today, getting it reimbursed through either (the pharmacy or medical benefi) would be a step in the right direction,” said Hornung.

Some have pointed to coverage of continuous glucose monitors as a forerunner. Private payers cover them on both,, said Hornung. Medicare covers the monitors on the pharmacy benefit but the lancets and the test strips on the medical benefit. “It is a pain in the neck,” Hornung said.