Radar on Drug Benefits

There is a widening gap between employers’ pharmacy benefit goals and what they are getting from PBMs, according to the panelists of a March 11 webinar presented by the National Alliance of Healthcare Purchaser Coalitions. 

Vertical integration of PBMs with insurers, mail-order pharmacies, retail pharmacies and more was intended to allow PBMs to have greater negotiating leverage to deliver better prices, said Kimberly Westrich, chief strategy officer of the National Pharmaceutical Council. “But when you look at the data…that’s not actually what’s happening,” she said. Spread pricing, inflated savings, self-preferencing and other practices “are not in alignment with employers optimizing the value of their health care dollar,” she added. 

Sens. Elizabeth Warren (D-Mass.), Ron Wyden (D-Ore.) and Bernie Sanders (I-Vt.) wrote a letter on March 10 to HHS Secretary Robert F. Kennedy Jr., regarding a report that Kennedy met with pharmaceutical and health care executives at President Donald Trump’s Mar-a-Lago club in Florida. They cited a Feb. 17 Wall Street Journal article that mentioned Kennedy was present at “several” of the dinners Trump hosted with executives who paid “millions of dollars” to attend. The senators noted that Kennedy vowed last year to “clean up corruption” and “stop the revolving door between industry and government.” They asked Kennedy to detail how many private meetings he attended with pharmaceutical industry executives, what was discussed at the meetings, how much money executives paid to attend the meetings and whether Kennedy or his campaign received payments from pharmaceutical companies, trade groups or employees since November 2024. Wyden is the Senate Finance Committee ranking member, while Sanders is the Senate Health, Education, Labor, and Pensions Committee ranking member. 

In comment letters submitted to the federal government, health insurers warn — in so many words — that CMS could be facing lawsuits if it finalizes a rule that expands Medicare and Medicaid coverage of medications that treat obesity. 

In fact, at least two comment letters from the health insurance industry point out that a recent Supreme Court decision makes it far easier for courts to determine that federal agencies have overstepped their authority. 

“The absence of Chevron deference makes it easier for groups to challenge a regulation on the grounds that it fails to comport with the underlying law, even if under Chevron deference the regulation reflects a reasonable interpretation of the law,” explains Suhasini Ravi, a senior associate at the Center for Health Policy and the Law at Georgetown University’s O’Neill Institute.  

Federal PBM reform legislation that was scuttled last year could still end up in the next federal spending bill. But one expert tells AIS Health that other congressional priorities may take precedence instead. In the meantime, a slew of states have introduced PBM reform bills of their own. 

In December, PBM reform was on the cusp of passing in a year-end spending bill but was thwarted when then-President-elect Donald Trump expressed disdain toward the size of the 1,500-page bill and asked for a suspension of the debt ceiling until 2027. Ultimately, a pared-down version was passed that omitted PBM reform and the debt ceiling provision. The PBM reform included several transparency provisions, delinked PBM reimbursement from Medicare Part D drug prices and required 100% pass-through of rebates to employer group health plans. 

Pharmacies owned by companies that own both health insurers and PBMs make up a significant share of the Medicare Part D market, and these “insurer-PBMs” meaningfully steered Medicare beneficiaries to their affiliated pharmacies, according to a new study published in JAMA Health Forum.

The researchers analyzed a 20% sample of Medicare Part D claims data from Medicare Advantage Prescription Drug (MA-PD) plans and stand-alone Prescription Drug Plans (PDPs) for 2021, which collectively covered more than 10.4 million beneficiaries. They found that 34.1% of all pharmacy spending, 37.1% of specialty pharmacy spending, and 32.1% of non-specialty pharmacy spending occurred through pharmacies owned by The Cigna Group, CVS Health Corp., Humana Inc., or UnitedHealth Group.