Radar on Drug Benefits

  • On Roe v. Wade Anniversary, Here’s a Closer Look at U.S. Abortion Access

    The Biden administration announced new measures to protect reproductive health care accessibility on the 51st anniversary of the Roe v. Wade ruling, which found that the U.S. Constitution protects the right to have an abortion. HHS, alongside the Labor and Treasury departments, released new guidance that instructs health insurers on how to comply with the Affordable Care Act’s requirements to cover contraception at no cost. For hospitals and provider associations, HHS and CMS launched new efforts to increase awareness about access to emergency medical care — including abortion services — required under the Emergency Medical Treatment and Labor Act.

    A year and a half after the Supreme Court’s decision in Dobbs v. Jackson Women's Health Organization — which reversed Roe v. Wade — access to abortion is uneven across the nation. As of January 2024, 14 states have made abortion illegal. Among the states without bans, the majority have at least one restriction on the books, such as limiting abortion access to just those who are early in pregnancy and imposing mandatory waiting periods. Arizona, North Carolina and Wisconsin, for example, currently have six abortion-limiting regulations in place, according to a KFF analysis.  

  • News Briefs: Tyson Drops CVS Caremark for Startup PBM

    Tyson Foods, Inc. dropped CVS Health Corp.’s Caremark PBM in favor of Rightway, a fee-based PBM partnered with Mark Cuban Cost Plus Drug Co. Rightway promises to save employers 15% on their pharmacy benefit costs. Tyson’s head of benefits, Renu Chhabra, told CNBC that concerning jumps in specialty drug spending were a key reason behind the move. CVS withheld data that Chhabra hoped to use to manage costs, she said. “We were going anywhere between 12% to 14% increases for pharmacy — and on a $200 million spend that’s quite a bit,” said Chhabra. “I wanted to look at Humira, and I wanted to see what the acquisition cost was…it was very difficult to get to those numbers. Part of this was to really get a partner who can help us organize the information, make sure we understand how to manage specialty, and really looking at how to get the best net cost.”
  • What’s Next For ICER: An Interview With New President Sarah Emond

    The Institute for Clinical and Economic Review’s (ICER’s) new president and CEO Sarah Emond took over the role from the organization’s longtime leader and founder Steve Pearson on Jan. 1, and in an interview at the J.P. Morgan Healthcare Conference in San Francisco, she discussed some of the pressing drug pricing issues on ICER’s radar for the year ahead.

    Emond has had a lengthy career at ICER, having worked for the organization for 14 years — most recently as vice president and chief operating officer, helping to lead strategic operations. She said the leadership change was part of a long and planned transition and Pearson continues to work as an advisor.

  • Obesity Meds, Gene Therapies, NASH Drug Make Payers’ Cost Concern List

    For years, payers have been concerned about the rising prices of prescription medications and how to cover newly approved drugs. Pharmaceutical experts tell AIS Health, a division of MMIT, that PBMs and plans will continue to be challenged in 2024 with similar issues, particularly when it comes to gene therapies, obesity medications and other expensive products.

    Andy Szczotka, Pharm.D., chief pharmacy officer at AscellaHealth, notes that more than half of pharmacy benefit spending is on specialty medications even though only a small percentage of members use those drugs.

    He says dealing with high-cost specialty products “is a focus for most payers” and adds there is a “large target on specialty drugs.”

  • CVS Removes Humira From Formulary — But the Fine Print Is Key

    CVS Health Corp.’s PBM, CVS Caremark, said recently that it will remove AbbVie’s immunosuppressive drug Humira (adalimumab) from its major national commercial template formularies. The move comes on the heels of a year in which 14 near-identical copies of the world’s best-selling drug entered the U.S. market after years of delays, leading major PBMs to generally put selections of several biosimilars on the same coverage tiers as their reference product.

    Yet while Wall Street analysts heralded CVS’s decision as an indication that it’s become a trailblazer in the biosimilar space, one prominent PBM critic remains skeptical of the company’s motivations — especially since CVS is working with Humira’s manufacturer on a new cobranded version of the drug.

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