RADAR on Drug Benefits

When it comes to Star Ratings for Medicare plans, 2023 represented a return to the status quo after CMS stopped making adjustments related to the COVID-19 public health emergency that had largely inflated plans’ performance. Stand-alone Prescription Drug Plans (PDPs) were no exception to that trend, but they also continued a phenomenon seen in prior years where their overall scores trailed that of the more comprehensive Medicare Advantage-Prescription Drug (MA-PD) plans. 

“In general, the PDP Star Ratings are somewhat lower than the average rating for MA contracts,” observes Shelly Brandel, a principal and consulting actuary at Milliman. That tends to happen every year, she adds, “so I think directionally the PDP Star Ratings have moved pretty similarly to MA Star Ratings [for 2023], but at a lower level.”

In its latest report highlighting notable drugs nearing FDA approval, UnitedHealth Group’s Optum Rx PBM singles out two therapies designated as orphan drugs and one that has been granted priority review. Experts tell AIS Health that payers deciding how to cover these drugs will undoubtedly have to weigh factors such as a high unmet need for treatment, the durability of patients’ response to the therapy, and potentially high price tags. 

For example, regarding the only non-orphan drug included in the report, Apellis Pharmaceuticals, Inc.’s pegcetacoplan, there are currently no other approved treatments for the condition it’s targeting, “so that will have an impact on how payers approach coverage,” says Bill Dreitlein, senior director of Pipeline & Drug Surveillance at Optum Rx.  

Since the COVID-19 pandemic began, the federal government has spent tens of billions of dollars purchasing vaccines, treatments and tests and providing them for free to the public. Congress has also passed legislation ensuring private and public payers cover those countermeasures for as long as the public health emergency (PHE) is in place. 

However, that may soon be ending as Congress has yet to authorize additional COVID-specific funding and the PHE is likely to expire sometime next year. That could lead to questions about access, pricing and insurance coverage, according to panelists who spoke during a Kaiser Family Foundation (KFF) webinar on Oct. 19.