Radar on Drug Benefits

Notable changes to the way breakthrough medical devices are covered by Medicare and other payers could be coming soon, with CMS poised to make some therapeutics eligible for Medicare coverage, and some stakeholders pushing for new legislation to expand digital therapeutic coverage. In the meantime, commercial health plans and PBMs are grappling with how best to cover prescription digital therapeutics (PDTs).

Health plans and PBMs have varying approaches to digital therapeutic reimbursement. Some plans may place one digital therapeutic in the medical benefit, while others may cover PDTs as part of a pharmacy benefit. That’s because PDTs occupy a unique space in the health benefits landscape: They aren’t pharmaceuticals, but they share many characteristics of a maintenance medication in practice.

States and the federal government have taken steps in recent years to increase access to medications to treat opioid use disorder (OUD), such as allowing prescribing via telehealth and easing other restrictions for providers. However, some of those policies are set to expire in the coming months and more needs to be done to ensure patients receive the much-needed treatments, health policy experts tell AIS Health, a division of MMIT.

A KFF analysis found a 24% increase from 2019 to 2022 in the dispensing of buprenorphine, one of three FDA-approved medications for OUD. A separate KFF report published last month showed that 63% of Medicaid enrollees with an OUD diagnosis received medication treatment in 2020.

One week before the Institute for Clinical and Economic Review released a white paper laying out ways to manage ultra-high-cost gene therapies, ICER President and CEO Sarah Emond shared frank views about the consequences that result when medications are priced far higher than they need to be.

“We’re making tradeoff decisions all the time,” Emond said during an April 16 presentation at the Academy of Managed Care Pharmacy annual conference in New Orleans. “Anyone who thinks that we are not rationing care in the United States is not paying attention. It has a lot to do with how good your health insurance is and how much money you have.”

If providers charged the same price as specialty pharmacies for specialty medications, $13.1 billion in spending on health insurance premiums and premium equivalents could have been avoided in 2024, according to a new analysis from the consulting firm Oliver Wyman, commissioned by AHIP.

Provider-administered drugs can be delivered directly to clinicians from specialty pharmacies — known as white bagging — or providers can purchase the drugs directly and store the drugs until they are needed for patient care, which is called “buy and bill.” When the “buy and bill” method is utilized, the providers can charge a markup for the drug that is passed through to the patient’s bill.

CarelonRx, the PBM arm of Elevance Health, Inc., has a new “comprehensive approach to specialty medication savings across pharmacy and medical benefits,” according to an April 22 press release. The new product will use “advanced analytics” to “identify members whose health is at the greatest risk,” which will prompt “a thorough review of a member’s clinical diagnoses, medications, whole-health integrated support, and a review of their site of care options.” At that point, identified members will receive “proactive pharmacist-led outreach to address any barriers to care, and to further coordinate integrated care with their whole health team, including medical and behavioral health professionals.” Elevance recently announced a pending deal to acquire Kroger Inc.’s specialty pharmacy division as it grows its Carelon health services division.

Sen. Bernie Sanders (I-Vt.) said on April 24 that he has launched an investigation into the “outrageously high prices” that Novo Nordisk is charging for its popular treatments for weight loss and Type 2 diabetes, Wegovy and Ozempic. In a letter to the Danish drugmaker’s CEO, Sanders — who chairs the Senate’s Health, Education, Labor and Pensions Committee — noted that the list prices for Wegovy and Ozempic ($1,349 and $969 per month, respectively) are far higher than what the drugs can be purchased for in countries like Canada and Germany. In his letter, Sanders requested information about how Novo Nordisk determined the prices for Ozempic and Wegovy, what it spent on research and development, and more.