Radar on Drug Benefits

Some findings from the new report by Pharmaceutical Strategies Group (PSG), an EPIC company, may have seemed like old news: AbbVie Inc.’s Humira (adalimumab) was the top specialty drug in terms of spend. Inflammatory treatments dominated the top 10 of those agents. But the 2024 Artemetrx State of Specialty Spend and Trend Report, released July 25, also revealed some new findings, including that rebates had a smaller impact in 2023 than they did the previous year and that cost per claim played a bigger role in the 2023 specialty drug trend than it did in the prior time frame.

PSG based the report — which is sponsored by Walmart Specialty Pharmacy — on integrated pharmacy and medical claims data from the book of business for its proprietary SaaS platform Artemetrx. In its eighth year, the newest report is based on 138 million medical claims and 136 million pharmacy claims. The findings are based mainly on commercial health plans.

A House Committee on Oversight and Accountability hearing on potential PBM reform legislation suggests there remains strong, bipartisan interest in crafting legislation that could have a significant impact on the sector, but also that any substantive actions will not come before next year.

The committee heard testimony from executives of the “big three” pharmacy benefit management companies, CVS Caremark, Express Scripts and United/Optum Rx, at its July 23 hearing on “transparency and accountability.” The hearing was the third in a series from the committee after previous sessions were held in May and September 2023.

Testifying before a House committee on July 23, executives of the three largest PBMs faced a grilling from lawmakers while trying their best to outline the reforms and transparency efforts they’ve voluntarily implemented in their businesses.

However, the executives’ answers to questions about group purchasing organizations (GPOs), especially when compared to their answers to similar questions at a 2023 hearing, suggest that the companies may still be resisting transparency in some respects.

As scrutiny of PBMs has reignited recently — with critics of the industry hoping to push through a reform measure by the end of the year and the Federal Trade Commission (FTC) reportedly poised to sue the largest PBMs over their contacting practices — the spotlight is also getting brighter on GPOs.

Although the approval of Kisunla (donanemab) earlier this month was celebrated by the Alzheimer’s Association as “real progress,” the challenge of getting commercial insurers to cover the drug will likely end up tempering that excitement.

Eli Lilly’s Kisunla, which received full FDA approval on July 2, is a once-monthly, IV-infused treatment for people with early symptoms of Alzheimer’s disease, including mild cognitive impairment and mild dementia. Like the drug Leqembi (lecanemab), which received full approval last July, Kisunla aims to slow the progression of Alzheimer’s by removing amyloid plaques from the brain. (The naturally occurring protein amyloid can create plaques when clumped together, and if those plaques build up excessively in the brain, it may lead to memory and cognitive issues associated with Alzheimer's disease.)