Radar on Drug Benefits

While a previous effort to force the disclosure of net drug prices was scuttled amid legal challenges, President Donald Trump recently made it clear that he hopes to revisit the issue amid a renewed push for health care price transparency. 

“There’s no more hope that this will go away,” says Chris O’Dell, senior vice president of market solutions with Turquoise Health, a company that cleans and aggregates pricing data from hospitals and health plans. “It’s going to happen, so get ready for it, research it, comment on it, and do what you can to prepare.” 

In defiance of some industry watchers’ expectations, there was no mass exodus from stand-alone Prescription Drug Plans (PDPs) to Medicare Advantage Prescription Drug (MA-PD) plans between 2024 and 2025, one prominent Part D actuary has observed. 

“Total enrollment was effectively flat from December [20]24 to February 2025; that’s a little bit at odds with what some might have expected,” explains Brooks Conway, principal with Oliver Wyman.  

As for why enrollment trends this year defied expectations, Avalere Health Principal Robin Duddy-Tenbrunsel points out that “there’s been quite a bit going on” in the Part D world. 

Extending inflation-based prescription drug rebates to all commercial health plans, rather than just applying them to the Medicare program, could potentially save as much as $8.1 billion annually, a recent Health Affairs study finds.

The Inflation Reduction Act (IRA) requires pharmaceutical manufacturers to pay rebates to Medicare if they raise prices faster than the rate of inflation for certain drugs. To gauge the effects of extending the program beyond Medicare, researchers analyzed 130 million claims — comprising 16,107 drugs — for 11 million enrollees in commercial plans in 2021. They found that if the IRA rebate program was applied to the entire commercially insured population, savings would be largely driven by a small number of drugs with high total spending.

A recent Institute for Clinical and Economic Review (ICER) report found that Trelegy Ellipta (fluticasone/umeclidinium/vilanterol) and Breo Ellipta (fluticasone/vilanterol), two chronic obstructive pulmonary disease (COPD) treatments, may have “incremental net health benefits” compared with generic alternatives. Both inhalers are manufactured by GSK and are among the 15 drugs chosen for the second round of Medicare drug price negotiations, which will set new maximum fair prices effective in 2027. 

Sarah Emond, ICER’s president and CEO, tells AIS Health that the nonprofit organization could not determine the treatments’ cost-effectiveness because CMS does not disclose the prices it pays for the treatments. However, Emond notes that ICER submitted the findings during the public comment period for the Medicare Drug Price Negotiation Program, which was authorized by the Inflation Reduction Act. And she says that “contributing our expertise to the body of evidence that CMS would consider is almost like a public service.” 

There is a widening gap between employers’ pharmacy benefit goals and what they are getting from PBMs, according to the panelists of a March 11 webinar presented by the National Alliance of Healthcare Purchaser Coalitions. 

Vertical integration of PBMs with insurers, mail-order pharmacies, retail pharmacies and more was intended to allow PBMs to have greater negotiating leverage to deliver better prices, said Kimberly Westrich, chief strategy officer of the National Pharmaceutical Council. “But when you look at the data…that’s not actually what’s happening,” she said. Spread pricing, inflated savings, self-preferencing and other practices “are not in alignment with employers optimizing the value of their health care dollar,” she added.