Radar on Drug Benefits

The U.S. health care system could save billions if it increases access to treatment for hepatitis C, now that a series of curative therapies approved in the 2010s have decreased in price, according to the Congressional Budget Office (CBO). However, one expert says that federal and state governments will have to force health plans — particularly Medicaid managed care organizations — to increase access to those therapies.

Doubling hepatitis C treatment access in Medicaid could save the federal government $7 billion over 10 years, the CBO found in a report published June 14. In addition, a 2023 white paper from researchers affiliated with the National Bureau of Economic Research found that a Biden administration budget request for a federal program to eliminate hepatitis C would diagnose and cure about 90% of all U.S. hepatitis C patients, saving the health care system $18.1 billion, of which $13.3 billion would accrue to the federal government.

Although the Supreme Court has already weighed in on one case regarding states’ ability to regulate PBMs, the top law enforcement officials in more than 30 states are asking the high court to review another case that they claim will remove lingering uncertainty about the limits of states’ authority.

In PCMA v. Mulready, the current case, the Pharmaceutical Care Management Association is challenging an Oklahoma law — the Patient’s Right to Pharmacy Choice Act — which sets geography-based access standards for pharmacy networks. Among other provisions, it also bans PBMs from using discounts or cost-sharing differences to push plan members to certain in-network pharmacies, particularly those owned by that same PBM’s parent company.

A recent survey from the Pharmaceutical Strategies Group (PSG) found that 33% of health plans and employers provide coverage for GLP-1 medications for obesity and 91% cover them for Type 2 diabetes. While an additional 19% of respondents said they were considering covering the drugs for obesity, plans and companies that do not cover the medications indicated they were primarily concerned with their high costs or considered them as lifestyle drugs rather than as pharmaceuticals to treat obesity as a disease.

“In an ideal world, if these drugs were really cheap, everyone would cover them for obesity,” says Morgan Lee, Ph.D., PSG’s senior director of research and strategy and one of the report’s authors. However, she notes GLP-1 medications such as Novo Nordisk’s Wegovy (semaglutide) and Eli Lilly & Co.’s Zepbound (tirzepatide) have a wholesale acquisition cost of about $13,000 per year, and more than 40% of the U.S. population is obese. If 40% of a payer’s members take GLP-1s, Lee says the financial impact could be “terrifying.”

Amazon Pharmacy revealed earlier this month that its RxPass subscription savings program is now available to “more than 50 million Medicare beneficiaries,” allowing those who are Prime members to get 60 common generic medications delivered for a $5 monthly fee. Industry experts tell AIS Health that they can see the appeal in such an offering — including both convenience and potential cost savings — but they aren’t expecting the newly expanded service to significantly impact the Medicare Part D space.

“To be very honest, when I read the news, I didn’t really give it too much of a second glance,” says Marc Guieb, Pharm.D., a consultant at Milliman. “In terms of big-picture market stuff, I don’t think this really is going to change much or have any sort of tangible effects.”

When designing their drug benefits packages, deciding how to approach GLP-1 medications was a top concern for plan sponsors, according to Pharmaceutical Strategies Group’s 2024 “Trends in Drug Benefit Design Report,” sponsored by Prescryptive Health. The report is based on surveys of 223 individuals representing employers, health plans and union/Taft-Hartley plans.

The report highlighted the complexities presented by the demand and high costs of GLP-1 drugs. In 2024, over 90% of all employers and health plans covered GLP-1s for Type 2 diabetes, while just over 30% covered these drugs for obesity. Of those who excluded the medications for obesity from coverage, 38% considered them too expensive to cover.