Radar on Drug Benefits

  • Most Payers Have Not Followed Blue Shield of California’s PBM Unbundling Model

    Blue Shield of California caught the attention of the industry last August when it announced a switch to a pharmacy benefits model using five vendors. While some insurers and plan sponsors have considered a similar move following Blue Shield’s revelation, benefits consultants tell AIS Health, a division of MMIT, that most payers continue to have a traditional arrangement where one PBM handles all pharmacy-related activities. They add that Blue Shield’s so-called unbundled approach could be difficult to manage and may not achieve significant cost savings.

    A survey released last month from the Pharmaceutical Strategies Group (PSG) found that 72% of health plan respondents had heard about Blue Shield of California’s change. Morgan Lee, Ph.D., PSG’s senior director of research and strategy and one of the report’s authors, noted during a June 18 webinar that the survey was conducted in February and March. As such, “we’ll probably continue to see [awareness of unbundling] increase over time,” Lee said.

  • Uptake of Humira Biosimilars Flattens, but Analysts See More Change Ahead

    Although CVS Health Corp.’s move to drop Humira from its main template formularies did help adalimumab biosimilars finally chip away at the blockbuster drug’s dominant market share, that effect appears to be leveling off, according to industry analysts.

    CVS said earlier this year that starting in the second quarter of 2024, it will remove AbbVie’s autoimmune condition treatment Humira from major national commercial formularies, instead preferring biosimilars including Sandoz’s Hyrimoz. Notably, CVS subsidiary Cordavis, which the firm launched in 2023, has a contract with Sandoz to commercialize a co-branded, low-list-price version of Hyrimoz. Cordavis also has a deal with AbbVie to produce a limited amount of co-branded version of Humira.

  • Report Details Providers’ Mounting Concerns With White Bagging

    White bagging continues to be a sore subject for providers, according to a June 21 Avalere Health report. As in past reports, providers surveyed by Avalere are concerned that white bagging can harm patients and lead to wasted medication — which can add up, since payers only use white bagging strategies for expensive specialty medications. The report also raised concerns that payer ownership of specialty pharmacies raises conflicts of interest and could accelerate provider consolidation.

    White bagging is a payer practice that significantly changes the customary dispensing and billing arrangements around provider-administered drugs. Until recently, providers used the “buy-and-bill” framework with regard to such drugs. In buy-and-bill transactions, which still account for the vast majority of specialty pharmacy care, providers purchase a specialty drug, stock it in their facility and charge a payer for it after administering the drug to a patient.

  • An Overview of Medicare Part D Enrollment, Costs in 2024

    Medicare Advantage Prescription Drug plans (MA-PDs) continued to gain more enrollees than stand-alone Prescription Drug Plans (PDPs) in 2024, according to a KFF analysis.

    As of 2024, about 53.1 million Medicare beneficiaries were enrolled in a plan with Part D prescription drug coverage, with 57% in MA-PDs and 43% in stand-alone PDPs. Two-thirds of enrollees receiving the low-income subsidies (LIS) — 9 million out of 13.7 million — chose MA-PDs in 2024. Among the 14 national PDPs, 11 of them lost non-LIS enrollees, with only Wellcare Value Script seeing significant membership growth (from 2.6 million to 3.7 million) due to its low monthly premium.

  • News Briefs: FDA Reveals Safety Concerns for Generics — but Doesn’t Pull Drugs

    Safety and efficacy data of generic versions of several drugs, including Pfizer Inc.’s Viagra (sildenafil) and Eli Lilly & Co.’s Cialis (tadalafil), may have been falsified, according to Bloomberg. Bloomberg on July 9 reported that the FDA in June notified drug manufacturers that data from Synapse Labs Pvt. Ltd., an Indian drug researcher, may have been used in hundreds of drugs currently on sale. The FDA was tipped off by European regulators about the problematic data. In an interview with Bloomberg, former FDA inspector Massoud Motamed expressed concerns that the affected drugs may have too much or too little of their active ingredient. However, the FDA has not revealed specifics about which drugmakers used Synapse’s data, citing confidentiality reasons, and has not suspended sales of any drugs — unlike EU regulators, who recommended that member states stop sales of certain drugs. Cherie Duvall-Jones, a spokesperson for the agency, told Bloomberg that "the FDA remains vigilant and will act should we identify safety issues."
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