Radar on Drug Benefits

The FDA on June 7 delivered its much-anticipated approval of Biogen Inc.’s Aduhelm (aducanumab-avwa), immediately stirring up a furor over its high cost, reigniting doubts about its effectiveness, and spurring speculation about how public and private payers will approach coverage for the first novel treatment approved for Alzheimer’s disease since 2003.

Alzheimer’s, which affects more than 6 million Americans and tens of millions of people worldwide, is marked by progressive cognitive and functional decline that eventually results in death. It kills more people than breast and prostate cancers combined and, along with other forms of dementia, is expected to cost the U.S. $355 billion this year alone, according to the Alzheimer’s Association.

✦ In a proposed rule issued on May 26, CMS delayed for six months a provision in a Trump administration-era rule that would have required drug manufacturers to report multiple Medicaid “best prices” connected to a value-based purchasing arrangement. The rule, finalized on Dec. 31, 2020, altered Medicaid “best price” rules — which dictate how rebates are calculated in the Medicaid Drug Rebate Program — by clarifying best price reporting requirements and enabling new models including year-to-year scheduled prices that could change in relation to patient outcomes.

✦ Thousands of health plans that sought to make their lawsuits against Cigna Corp. into a class action were stymied by a federal judge on May 20, according to a Modern Healthcare article. The self-funded health plans alleged that Cigna overcharged their members for prescription drugs by secretly clawing back the difference when a given drug costs less than a patient’s copayment amount and prohibiting pharmacists from telling patients their drugs could cost less without insurance. U.S. District Judge Jeffery Alker Meyer said plan contracts varied too widely for a class-wide ruling.

OptumRx, the PBM subsidiary of UnitedHealth Group, claims that pharmacy waste, fraud and abuse increased in 2020 due to the pandemic — and that independent pharmacies are to blame. While experts won’t rule that out, they also observe that new fraud detection technology might have more to do with the eye-popping findings than any perceived shortcomings of independent pharmacies.

OptumRx tells AIS Health, a subsidiary of MMIT, that pharmacy waste, fraud and abuse increased during 2020. Heidi Lew, Pharm.D., vice president of pharmacy network audit, asserted via email that in 2020, OptumRx:

Some 70% of pharmacists have taken on new job responsibilities — ranging from childhood immunizations and diagnostic testing to patient counseling on care and payment options for their medications — during the COVID-19 pandemic, a survey from CoverMyMeds shows.

This trend toward an expanded scope of practice for pharmacists, which had been building prior to the pandemic, accelerated with federal and state actions to relax restrictions in order to improve access to care during the public health emergency, experts say. While pharmacists in some states may lose ground on their practice scope when the emergency ends, it’s likely that more pharmacists will retain the ability to vaccinate children and perform diagnostic tests.