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.
Total inflation-adjusted spending on prescription drugs grew from $520 billion in 2016 to $603 billion in 2021, before accounting for rebates, according to a report published by HHS’s Assistant Secretary for Planning and Evaluation (ASPE). Retail drug expenditures represented about 70% of prescription drug spending in 2021. For retail prescription drugs, there was a 13% increase in drug spending over the five years studied, yet only a 5.7% increase in the number of prescriptions.
Meanwhile, more and more Americans received their drugs from mail order pharmacies, clinics and home health care organizations between 2016 and 2021.
A congressional panel found that major PBMs and health insurers are charging members cost sharing and imposing other coverage requirements on birth control products in violation of the Affordable Care Act. The “investigation identified more than 30 birth control products for which most health insurers and PBMs reviewed impose cost-sharing requirements or coverage exclusions,” according to a press release. Among the companies examined were CVS Health Corp., UnitedHealth Group, Elevance Health Inc., Cigna Corp., Humana Inc. and Prime Therapeutics, a PBM owned by a consortium of Blues affiliates. “From 2015 to 2021, companies denied exceptions requests on average four or more times out of ten,” the press release added.
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