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UPMC Health Plan
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UPMC Health Plan Announces Innovative, Value-Based Agreement with AstraZeneca

Value-based contract for BRILINTA® (ticagrelor) improves member access to the medicine and uniquely includes two-sided financial risk

PITTSBURGH (Jan. 28, 2019) – UPMC Health Plan and AstraZeneca today announced the initiation of a pioneering value-based contract effective Jan. 1, 2019, for UPMC for Life Medicare members who are prescribed BRILINTA® (ticagrelor), a medication used to lower a patient’s chances of having another heart attack or dying from one in the 12 months following a heart attack.

The goal of the contract is to align the incentives of the manufacturer, AstraZeneca, with UPMC Health Plan by connecting reimbursement for BRILINTA® to clinical outcomes in a real-world population. Specifically, reimbursement for the medication will be linked to cardiovascular outcomes for people treated with BRILINTA® following a recent hospitalization for heart attack or unstable angina.

This value-based contract is groundbreaking in two ways: first, the contract reduces out-of-pocket costs for UPMC for Life Medicare members by offering BRILINTA® at a generic drug tierthat could save a member hundreds of dollars over a year. The other unique aspect of this agreement is that it includes a shared or two-sided financial risk component between UPMC Health Plan and AstraZeneca. Clinical outcomes will determine the level of shared costs.

Development of this value-based contract was led by the Center for Value-Based Pharmacy Initiatives, the UPMC Insurance Services Division’s nonprofit research group, and supported by leaders across UPMC’s payer and provider systems, the University of Pittsburgh, and in collaboration with AstraZeneca. Specifically, clinical and academic leadership helped determine which outcomes to measure; clinical leadership supported health plan formulary adjustments; and patients were surveyed to ensure that the agreement reflects their priorities.  

“This type of contract reflects the innovative work that we are leading at the Center for Value-Based Pharmacy Initiatives,” said Chronis Manolis, RPh, chief pharmacy officer at UPMC Health Plan. “For example, by incorporating two-sided risk into the reimbursement algorithm, we move further into true risk-based contracting that financially aligns key healthcare stakeholders. In addition, by offering BRILINTA® to patients at a generic tier copay, we improve access to BRILINTA® for our members and make progress toward removing cost as a barrier to medication adherence. Our goal at the Center for Value-Based Pharmacy Initiatives is to change the paradigm around how we pay for medicine while adding incentives in our member care model that improve our members’ access to high quality medicines.”

“In alignment with our commitment to ensuring patient access, lowering patient costs and sustaining innovation, AstraZeneca is pleased to collaborate with UPMC Health Plan on this novel agreement to lower out-of-pocket costs for UPMC for Life Medicare patients through dual-sided risk and proud to stand behind the value of BRILINTA® in improving patient outcomes,” said Rick R. Suarez, senior vice president, US Market Access, AstraZeneca. 

Chester “Bernie” Good, MD, MPH, FACP, senior medical director for the Center for Value-Based Pharmacy Initiatives notes, “We believe this value-based contract is unique and will fundamentally change the strategies for future contracts. The ultimate winner in this agreement is our members who stand to have greater access to an effective treatment option. The fact that UPMC Health Plan is willing to enter into a two-sided risk agreement underscores our commitment to leveraging the strengths of our academic clinical experts to improve clinical outcomes in a high-risk patient population.”

UPMC Health Plan will create a wraparound care model to ensure treatment optimization and removal of many of the traditional barriers to care. Leveraging internal clinical resources, integrated clinical collaboration models, value-based provider reimbursement constructs, and award-winning member services, the goal is to create an environment where the outcomes of UPMC Health Plan members are maximized.

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About UPMC Insurance Services Division

The UPMC Insurance Services Division is owned by UPMC, a world-renowned health care provider and insurer based in Pittsburgh, Pa. The UPMC Insurance Services Division—which includes UPMC Health Plan, WorkPartners, UPMC for Life, UPMC for You, UPMC for Kids, and Community Care Behavioral Health—offers a full range of group health insurance, Medicare, Special Needs, CHIP, Medical Assistance, behavioral health, employee assistance and workers' compensation products and services to more than 3.4 million members. For more information, visit www.upmchealthplan.com.

UPMC for Life has a contract with Medicare to provide HMO and PPO plans. Enrollment in UPMC for Life depends on contract renewal. UPMC for Life is a product of and operated by UPMC Health Plan Inc., UPMC Health Network Inc., and UPMC Health Benefits Inc.