Radar on Drug Benefits

  • At Investor Conferences, Execs Paint PBM Reform as Afterthought

    During recent investor conference presentations, executives from major managed care companies expressed little concern that PBM reform — which once seemed like a much more acute threat — will impact their businesses anytime soon. Those remarks come even as a large coalition of interest groups is hoping to push lawmakers into refueling the issue’s momentum. 

    “I would say it is difficult to get alignment and bipartisan support on the specifics relative to PBM [reform],” CVS Health Corp. CEO Karen Lynch said during a “fireside chat” on May 29 at the Bernstein Strategic Decisions Conference. “I think if anything happens, it'll be on transparency, but you have seen time and time again that there's been some challenges.” 

  • Midsize Plans Struggle to Pay for Cell, Gene Therapies, Execs Say

    It's no secret that health plans are concerned that they may not be able to afford gene and cell therapies with new or anticipated approvals. With expensive launches on the horizon, plans are searching for payment models that can grant patients access to lifesaving or life-changing therapies without blowing budgets.  

    Those concerns are particularly acute for smaller, regional health insurers and employer plan sponsors. Those payers may have tight balance sheets and lack the pricing advantages that national insurers can leverage in negotiations with manufacturers. Midsize plan executives say their organizations are figuring out what to do as they go along.  

  • Medicaid Programs Are Slow to Cover GLP-1s, but That Could Soon Change

    Most states do not cover GLP-1s and other obesity medications for Medicaid beneficiaries, according to a recent analysis. However, one of the report’s authors tells AIS Health, a division of MMIT, that more states are pondering whether to place GLP-1s on their formularies and weighing the drugs’ health benefits with their high costs. 

    The Strategies to Overcome and Prevent (STOP) Obesity Alliance and the Obesity Action Coalition (OAC) released the report on June 3 based on data from fee-for-service and managed Medicaid programs in 2023. STOP, which is housed within the Milken Institute School of Public Health at George Washington University, conducts research, makes policy recommendations and develops online resources. OAC is an advocacy organization with more than 80,000 members. 

  • Optum Rx’s PBM Pricing Model May Have Hidden Costs

    Experts say they’re skeptical that a pricing tool unveiled on May 20 by Optum Rx, UnitedHealth Group’s PBM division, will make significant changes to the PBM business model or generate major savings for plan sponsors. Indeed, some experts say that the model, Clear Trend Guarantee, could in practice be used to obscure rebate revenue that plan sponsors would otherwise collect. 

    According to a UnitedHealth press release, the new product “combines guarantees into a single per member cost” that “will offer drug benefit plan sponsors greater predictability of pharmacy spend to help manage total lowest net cost.”  

  • More MA Enrollees Are Facing Step Therapy Requirements for Part B Drugs

    Over half of Medicare Advantage enrollees were in plans that applied step therapy to the 10 most commonly used rheumatoid arthritis (RA) medications covered by Medicare Part B in 2023, according to a recent Avalere analysis.

    Since 2019, CMS has given MA plans the ability to use step therapy protocols — meaning a patient may be required to try a less expensive drug before moving to the more expensive one — for physician-administered and other Part B medications. Avalere analyzed MA plans’ annual medical policy and formulary restrictions for 22 RA drugs from 2018 to 2023 and found that the percentage of MA beneficiaries in plans that use step therapy has increased steadily since 2019. For two of the drugs studied, 78% of enrollees were in MA plans that applied step therapy in 2023.

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