Radar on Drug Benefits
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MedPAC Explores Drug Coverage Plan Problems as Part D Stand-Alone Plan Access Declines
The Medicare Payment Advisory Commission (MedPAC) is analyzing the differences between Medicare outpatient drug coverage in Medicare Advantage prescription drug (MA-PD) plans and stand-alone Prescription Drug Plans (PDP), ideally to help preserve stand-alone plans as an ongoing option for beneficiaries.
Concerns about declines in the number and attractiveness of PDPs in recent years relative to MA-PD plans, which appears to be exacerbated by the Part D redesign established by the Inflation Reduction Act, is driving the work. MedPAC discussed the issue at its Nov. 7 public meeting.
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News Briefs: CMS Proposes Rule Expanding Medicare, Medicaid Coverage of Anti-Obesity Drugs
CMS in a proposed rule issued Nov. 26 included a provision that would significantly expand Medicare and Medicaid beneficiaries’ access to anti-obesity medications. Currently, Medicare does not cover FDA-approved weight loss medications such as Wegovy (semaglutide) or Zepbound (tirzepatide), but it does cover those drugs when used to treat diabetes under the brand names Ozempic and Mounjaro, respectively. Under the newly proposed rule, CMS is proposing to reinterpret the Medicare statute, starting in 2026, “to no longer exclude anti-obesity medications for the treatment of obesity from coverage under Medicare Part D and to require Medicaid programs to cover these medications when used to treat obesity,” CMS said. Just 13 state Medicaid programs covered GLP-1s like Wegovy and Zepbound for treating obesity as of August 2024, according to KFF. The Congressional Budget Office estimated in October that authorizing Medicare to cover anti-obesity medications would increase federal spending, on net, by about $35 billion from 2026 to 2034. But CMS estimated that, if implemented, the new proposal would increase federal costs by $24.8 billion due to expanded Part D coverage and $14.8 billion due to expanded Medicaid coverage, over a 10-year period.
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From Lame Duck to GOP Trifecta, Path for PBM Reform Remains Fuzzy
With Donald Trump set to be the 47th president and Republicans in control of both chambers of Congress, 2025 is shaping up to be a year in which the GOP has enough political might to pass PBM reform — if it has the political will.
Yet two pharmaceutical industry trade groups do not appear to be counting on Republicans’ ability to quickly prioritize a health care issue. Instead, the Pharmaceutical Research and Manufacturers of America (PhRMA) and the National Association of Manufacturers (NAM) are both launching ad blitzes aimed at pressing Congress to target PBMs before the year is over.
“As Congress returns for the final legislative session, they have an opportunity to pass PBM reform that will make medicines more affordable and accessible for patients,” stated a Nov. 11 press release from PhRMA about its new ad campaign.
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While Costs Have Fallen for Hepatitis C Drugs, Medicaid Programs Still Restrict Access
Several state Medicaid programs continue to restrict access to hepatitis C medications that could cure beneficiaries, reduce health inequities and decrease health care costs, according to a JAMA Network Open study authored by Centers for Disease Control and Prevention (CDC) employees. Nathan W. Furukawa, M.D., the lead author, tells AIS Health that while the restrictions have eased over time, more needs to be done to help patients and eliminate a disease that has multiple curative treatments.
The authors noted that since the FDA first approved oral direct-acting antivirals (DAAs) for hepatitis C in 2013, the medications have proven to be associated with cure rates of greater than 95% within 8 to 12 weeks. However, usage of the medications has been less than expected in part because payers are wary of their high costs. For instance, they said DAAs cost between $84,000 and $94,500 per treatment initially, although the costs have fallen to $11,500 to $17,000 after rebates and pharmacy discounts, according to an estimate this summer from the Congressional Budget Office (CBO). Common DAAs include Sovaldi (sofosbuvir) and Harvoni (ledipasvir/sofosbuvir).
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More Commercial Health Plan Enrollees Have Copay Maximizers Than Accumulators in 2024
Copay maximizer programs are gaining popularity among payers while copay accumulators appear to be losing some of their appeal, according to the annual Copay Accumulator & Maximizer Programs Special Report published by AIS Health’s parent company, MMIT. The report was based on surveys of 35 commercial insurers and PBMs representing 121.0 million lives.
About 39% of people were enrolled in plans with copay accumulators in 2024 on average, down from 47% in 2023. And 47% of enrollees were in plans with copay maximizer programs. On average, payers anticipated that about 48% and 57% of plan members will be covered by plans with copay accumulators and maximizers within the next 12 months, respectively.
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