MSB (ASX) Ann: Ryoncil Pricing Set and Available This Quarter

Originally posted by Phaedrus: ↑

Hi @Hawk70,

Leaving aside a discussion about ASX market sensitivity for the minute, IMO people are struggling with correctly reading the quite public notices re RYONCIL which are available all over the internet atm. I believe the US forum poster was a little excited & misread the details, that's all.

As I read announcements, BCBCM i.e. Blue Cross Blue Shield of Michigan, which is a subsidiary of the integrated health system Elevance Health made clear its position on RYONCIL coverage at the start of January, not March 2025. It was one of the first divisions of a major US health system incorporating insurance i.e. a payer to do so, viz:

You can see that coverage is afforded for members covered by Blue Cross commercial & BCN commercial policies from the earlier date. Only the coverage under BCN Advantage and Medicare Plus Blue was delayed until March 3rd.

I can understand that the man in the street will struggle with the concepts involved e.g. prior authorization, stepwise therapy access, and other features of the USA's "managed utilization" system, not ot mention the byzantine structures under which USA healthcare insurance operates. HC:MSB posters may not even be aware that there are myriad State-level entities which are integrated in these giant healthcare insurers e.g. with ElevanceHealth:

Whew. And that's just Elevance. The extent to which they share policies and procedures is not spelled out to the general public, but we might safely assume that they'll all use similar service codes e.g. J3590 or J3490 or the C- equivalents for those services 'Not Otherwise Covered'. In due course there will be a product code specifically for the prescribed treatment with RYONCIL, but not yet.

However, again IMO, the question to be asked now shouldn't be 'when will coverage be afforded?', because I believe a number of insurers have made clear that service coverage is afforded, subject to the insurers own utilization management requirements, as in the above notice.

Rather, a better question might be 'what, if any, conditions are being applied to the prior authorization request requirements that physicians & MSB (working in tandem) might have difficulty with satisfying before the end of March?'.

Apart from the discounting/ rebating agreement required by Medicaid in connection with its own national coverage at a State level, & based on AWP rather than any one WAC, I really don't think there'd be too many that would even look like a hurdle, & so I think there'll be an increasing number of treatments commencing with complete processing through Elevance Health, Cigna, Centene, Hunana etc & of course - the biggest - UnitedHealth as we approach month end.

So, getting back to your original question, I think that the market sensitivity that one might have thought went with coverage is really a sensitivity to the satisfaction of prior authorization requirements, because unless & until the physicians satisfy those requirements there won't be effective coverage.

Cheers all
GLTALTH

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Well, there you go.

Having talked about 'misreading the details' I then went & did it myself with Blue Cross Blue Shield of Michigan. So, apologies all round - on rechecking the situation is that, although Blue Cross Blue Shield of Michigan does indeed offer the Blue Cross healthcare insurance plans I posted above i.e. including the mentioned Medicare Advantage plans, it is not a subsidiary of Elevance Health as is each of the Anthem Blue Cross and Blue Shield licensee corporations.

Elevance Health - which is a for-profit integrated healthcare system - has swallowed a large number of other State-based Blue Cross Blue Shield not-for-profits, including all of those I listed in my previous post. You can read about it here: https://en.wikipedia.org/wiki/Blue_Cross_Blue_Shield_Association

But not Blue Cross Blue Shield of Michigan, which remains a ~ 4.5million member not-for-profit licensee (owned by a mutual fund). And there are many other State-based not-for-profit insurers/ payers who offer licensed Blue Cross Blue Shield plans under mutual fund or coop ownership e.g. Blue Shield of California, BlueCross BlueShield of South Carolina, or Horizon Blue Cross Blue Shield of New Jersey.

It seems the not-for-profits are far more generous with information about the extent & conditions of their coverage of RYONCIL under those plans than other for-profit Medicare Advantage plan issuers, possibly because they're OK with higher quality drugs.

But regardless, it seems the major for-profits and the not-for-profits that are individual licensees of Blue Cross Blue Shield healthcare plans do work & can contract cooperatively beyond their individual State or organisational boundaries - a prime example is the Synergie Medication Collective initiative representing ~100 million Americans.

Why was that important? Here's one reason:

And here's a particular list that Mesoblast would have been hoping to make by 1 January 2025, as did CASGEVY and LYFGENIA with "preferred" status, notwithstanding that RYONCIL has no current competition up to 12 years of age:

More later about this & other initiatives for a trade-off with manufacturers in speeding up access to very expensive cell & gene tech through prior authorization programmes & other managed utilization systems. No doubt these negotiations have been continuing. For more background you can see this link here.

Cheers all
GLTALTH