Radar on Drug Benefits

  • Can PBMs Keep Their Lofty GLP-1 Cost Control Promises?

    As demand for GLP-1s has grown, so has the desire of plan sponsors and other payers to avoid covering the costly drugs as "lifestyle" products — instead, they want to allow only patients who will derive clear medical benefits from GLP-1s to use them. To address that desire, vertically integrated payer-PBMs, among other vendors, have launched buy-up services for commercial plan sponsors that promise to curb demand for GLP-1s by making other weight loss care more available to patients.

    Experts say it’s not clear whether those programs will make a difference for patients — or be worth the money for payers.

  • AHIP Panelists: Accelerated Approval, IRA Uncertainty Worry Health Plans

    For health plans, managing prescription drug coverage has become a highly complex task for myriad reasons, including never-ending regulatory changes and ever-rising prices. And that task is made even more difficult by the fact that an increasing number of drugs are coming to market with limited evidence that they are effective, panelists said during a March 13 session of the AHIP Medicare, Medicaid, Duals & Commercial Markets Forum in Baltimore.

    “One of the challenges for insurers going forward will be the increasing need to manage uncertainty,” said Daniel Ollendorf, Ph.D., chief scientific officer at the Institute for Clinical and Economic Review (ICER). Many drug launch prices, he said, “are being driven by approvals that happen on an accelerated basis with very limited evidence.”

  • Lame Duck or Lost Cause? Opinions Vary on PBM Reform’s Prospects

    When President Joe Biden signed a $460 billion government funding bill on March 9, that legislation was missing something that numerous legislators and other stakeholders have long been pushing for: PBM reform.

    Depending on whom you ask, the omission either represents a temporary setback or a sign that it will be a long time before any federal legislation passes that successfully alters major PBMs’ much-criticized business practices.

    “There’s still incredible bipartisan, widespread support for action on these issues,” says Joe Shields, managing director of Transparency-Rx, a coalition of smaller PBMs pushing for reform measures targeting their industry-dominant rivals. “We expect there will be action on these issues; that action could be in a matter of weeks, at least from what I’m hearing of some cadence coming out of Capitol Hill.”

  • PBMs Place Biosimilars on Preferred Tiers, yet Adoption Varies by Product

    PBMs often place biosimilar medications on preferred formulary tiers soon after the drugs hit the market, a change from a few years ago, when payers were more hesitant to cover biosimilars, according to a recent Cardinal Health report. However, one of the report’s authors tells AIS Health that PBMs in some cases have kept the reference biologic product on their preferred tier as well, leading to slower adoption of biosimilars.

    For instance, Fran Gregory, Pharm.D., Cardinal Health’s vice president of emerging therapies, notes that CVS Health Corp.'s Caremark, The Cigna Group's Express Scripts and UnitedHealth Group's Optum Rx all added Humira (adalimumab) biosimilars to their national preferred formularies when they launched last year. Gregory says those PBMs were “very strategic” about which of the nine Humira biosimilars to place in a preferred tier, analyzing the wholesale acquisition costs (WACs) and concentrations of the products and tailoring them “based on the lines of business they’re serving.” But the payers all put the same tier as the biosimilars, which Gregory says “is where the challenge lies” with adoption.

  • Alternative Payment Policies May Help Medicare Part B Reap Greater Savings From Biosimilars

    The growing use of biosimilars has reduced spending in the Medicare Part B program, but there are opportunities to further reduce costs — through greater use of more affordable biosimilars and through the implementation of different payment policies, according to a study published by the HHS Office of Inspector General (OIG).

    The OIG analyzed the average sales prices, utilization and costs of 21 biosimilar drugs and their reference biologic products in the Medicare Part B program between 2015 and 2021. The agency found that overall use rate of biosimilars in Part B jumped from 18% in 2015 to 62% in 2021. While the adoption of biosimilars has lowered both the prices of biologics and biosimilars, Part B spending could have been reduced by $179 million in 2021 if the five biosimilars that cost less than their reference products — epoetin alfa, infliximab, bevacizumab, rituximab and trastuzumab — had been used at the same rate as the most widely used biosimilar, filgrastim.

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