Radar on Drug Benefits
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More MA Enrollees Are Facing Step Therapy Requirements for Part B Drugs
Over half of Medicare Advantage enrollees were in plans that applied step therapy to the 10 most commonly used rheumatoid arthritis (RA) medications covered by Medicare Part B in 2023, according to a recent Avalere analysis.
Since 2019, CMS has given MA plans the ability to use step therapy protocols — meaning a patient may be required to try a less expensive drug before moving to the more expensive one — for physician-administered and other Part B medications. Avalere analyzed MA plans’ annual medical policy and formulary restrictions for 22 RA drugs from 2018 to 2023 and found that the percentage of MA beneficiaries in plans that use step therapy has increased steadily since 2019. For two of the drugs studied, 78% of enrollees were in MA plans that applied step therapy in 2023.
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News Briefs: State Officials Urge SCOTUS Review of PBM Regulation Case
A bipartisan group of state attorneys general recently filed an amicus brief with the Supreme Court, asking it to review an appeals court decision that limited states’ ability to regulate PBMs. In August 2023, the U.S. Court of Appeals for the Tenth Circuit ruled to block an Oklahoma law that contained provisions such as setting uniform standards for pharmacy networks and banning PBMs from using discounts to drive customers to pharmacies owned by their parent companies. That ruling was the result of a challenge to the Oklahoma law brought by the Pharmaceutical Care Management Association (PCMA). In PCMA v. Mulready, the PBM trade group argued that Oklahoma’s law is preempted by the Employee Retirement Income Security Act of 1974 (ERISA) and the statues governing Medicare Part D. But in their brief urging the Supreme Court to review the case, Minnesota Attorney General Keith Ellison (D) and his colleagues argue that the Tenth Circuit’s broad approach to federal preemption would “severely and unduly impede states’ abilities to protect their residents and regulate businesses.” In a similar case regarding an Arkansas law regulating PBMs, Rutledge v. PCMA, the Supreme Court rejected the PBM trade group’s ERISA-preemption argument.
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Plans Take Wait-and-See Approach to Vendors Promising Help With Weight Loss Medication Costs
As the use of and interest in GLP-1 medications for weight loss increases, numerous vendors are pitching self-insured health plans on solutions to manage the demand and high costs of the medications. However, benefits experts say employers are approaching these outside companies with caution and are still trying to figure out how to manage the significant expenses associated with GLP-1 drugs.
Chantell Sell Reagan, Pharm.D., WTW’s national pharmacy clinical leader, estimates that about 25 to 30 vendors are marketing solutions to employers to help with FDA-approved weight loss medications such as Novo Nordisk’s Wegovy (semaglutide) and Eli Lilly & Co.’s Zepbound (tirzepatide). Wegovy and Zepbound are also approved to treat type 2 diabetes under the brand names Ozempic and Mounjaro, respectively.
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Studies: IRA Will Spur Medicare Biosimilar Adoption — and Shift Costs to Part D Plans
Medicare Part D plans are likely to revise their biosimilar formulary management policies as a result of recent regulatory changes, not least the Inflation Reduction Act (IRA). With the IRA-mandated overhaul of the Part D benefit taking effect year, Part D payers will be on the hook for a greater share of catastrophic drug costs, which are likely to include biosimilars.
A study in Health Affairs released in May makes the case that the longstanding gap in the coverage of biosimilar products between employer-sponsored insurance plans and Medicare Part D plans is likely to shrink in 2025, when several key components of the IRA take effect.
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2023 Drug Trends Included GLP-1s, Humira Biosimilars, $0 Cost Share
Notable pharmacy benefit trends in 2023 claims data included increased use of GLP-1s for weight loss, shifting market dynamics amid high demand for AbbVie Inc.'s Humira (adalimumab) and its biosimilar competitors and increasing approval of expensive gene therapies. All this took place amid “persistent price inflation” across most drug categories, according to a new report by PBM analytics firm Xevant.
According to Xevant’s 2023 Drug Trend Report, which analyzed pharmacy claims data from its commercial plan clients, 2023 plan-paid amounts across all brand and generic non-specialty and specialty drugs went up an average of 20% from 2022. In addition, the number of specialty prescriptions processed by plans increased by 11% in 2023. GLP-1 utilization increased by 400%, while claims for Humira and its biosimilars increased by 25%.
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