Radar on Drug Benefits

During recent investor conference presentations, executives from major managed care companies expressed little concern that PBM reform — which once seemed like a much more acute threat — will impact their businesses anytime soon. Those remarks come even as a large coalition of interest groups is hoping to push lawmakers into refueling the issue’s momentum. 

“I would say it is difficult to get alignment and bipartisan support on the specifics relative to PBM [reform],” CVS Health Corp. CEO Karen Lynch said during a “fireside chat” on May 29 at the Bernstein Strategic Decisions Conference. “I think if anything happens, it'll be on transparency, but you have seen time and time again that there's been some challenges.” 

It's no secret that health plans are concerned that they may not be able to afford gene and cell therapies with new or anticipated approvals. With expensive launches on the horizon, plans are searching for payment models that can grant patients access to lifesaving or life-changing therapies without blowing budgets.  

Those concerns are particularly acute for smaller, regional health insurers and employer plan sponsors. Those payers may have tight balance sheets and lack the pricing advantages that national insurers can leverage in negotiations with manufacturers. Midsize plan executives say their organizations are figuring out what to do as they go along.  

Most states do not cover GLP-1s and other obesity medications for Medicaid beneficiaries, according to a recent analysis. However, one of the report’s authors tells AIS Health, a division of MMIT, that more states are pondering whether to place GLP-1s on their formularies and weighing the drugs’ health benefits with their high costs. 

The Strategies to Overcome and Prevent (STOP) Obesity Alliance and the Obesity Action Coalition (OAC) released the report on June 3 based on data from fee-for-service and managed Medicaid programs in 2023. STOP, which is housed within the Milken Institute School of Public Health at George Washington University, conducts research, makes policy recommendations and develops online resources. OAC is an advocacy organization with more than 80,000 members. 

Experts say they’re skeptical that a pricing tool unveiled on May 20 by Optum Rx, UnitedHealth Group’s PBM division, will make significant changes to the PBM business model or generate major savings for plan sponsors. Indeed, some experts say that the model, Clear Trend Guarantee, could in practice be used to obscure rebate revenue that plan sponsors would otherwise collect. 

According to a UnitedHealth press release, the new product “combines guarantees into a single per member cost” that “will offer drug benefit plan sponsors greater predictability of pharmacy spend to help manage total lowest net cost.”