Radar on Drug Benefits

  • Rise of GLP-1s Puts Growing Pressure on Medicaid

    One in five state Medicaid programs covered at least one anti-obesity medication in 2023, while the amount of reimbursement for these drugs has increased dramatically over the past decade, according to a recent JAMA study.

    The researchers studied state Medicaid coverage policies for six anti-obesity drugs approved by the FDA through 2022 — orlistat, lorcaserin, phentermine-topiramate, bupropion-naltrexone, liraglutide, and semaglutide. For the two GLP-1s — liraglutide and semaglutide — the study examined both their branded versions for obesity treatment (Saxenda and Wegovy) and the versions to treat diabetes (Victoza and Ozempic). (It is likely, per news reports, that a substantial amount of diabetes-coded utilization of GLP-1s is actually off-label weight loss utilization.)

  • News Briefs: Amazon Pharmacy Teams Up With Lilly

    Amazon.com Inc’s pharmacy division will be the exclusive home delivery partner for Eli Lilly & Co.’s direct-to-consumer business, Lilly Direct, which will distribute GLP-1s, among other drugs. In addition, the e-commerce giant now offers same-day delivery of many medications in New York and Los Angeles; it already offered same-day delivery in Austin, Indianapolis, Miami, Phoenix and Seattle. Analysts were positive about the LillyDirect deal: GlobalData’s Costanza Alciati wrote on March 14 that “Surely, by facilitating its medicines’ access in the world’s biggest obesity market, Eli Lilly made a great move to promote [GLP-1] utilization over competitor Novo Nordisk [A/S].” Bank of America analyst Allen Lutz wrote on March 13 that while “Amazon’s entrance into the pharmacy space has been underwhelming,” the LillyDirect deal “reflect[s] a shift in consumer preferences” that Amazon is wise to capitalize on. Lutz added that “patients taking GLP-1 drugs for the first time in 2024 could be introduced to Amazon’s mail pharmacy for the first time, which could potentially create greater awareness of the platform.”
  • Can PBMs Keep Their Lofty GLP-1 Cost Control Promises?

    As demand for GLP-1s has grown, so has the desire of plan sponsors and other payers to avoid covering the costly drugs as "lifestyle" products — instead, they want to allow only patients who will derive clear medical benefits from GLP-1s to use them. To address that desire, vertically integrated payer-PBMs, among other vendors, have launched buy-up services for commercial plan sponsors that promise to curb demand for GLP-1s by making other weight loss care more available to patients.

    Experts say it’s not clear whether those programs will make a difference for patients — or be worth the money for payers.

  • AHIP Panelists: Accelerated Approval, IRA Uncertainty Worry Health Plans

    For health plans, managing prescription drug coverage has become a highly complex task for myriad reasons, including never-ending regulatory changes and ever-rising prices. And that task is made even more difficult by the fact that an increasing number of drugs are coming to market with limited evidence that they are effective, panelists said during a March 13 session of the AHIP Medicare, Medicaid, Duals & Commercial Markets Forum in Baltimore.

    “One of the challenges for insurers going forward will be the increasing need to manage uncertainty,” said Daniel Ollendorf, Ph.D., chief scientific officer at the Institute for Clinical and Economic Review (ICER). Many drug launch prices, he said, “are being driven by approvals that happen on an accelerated basis with very limited evidence.”

  • Lame Duck or Lost Cause? Opinions Vary on PBM Reform’s Prospects

    When President Joe Biden signed a $460 billion government funding bill on March 9, that legislation was missing something that numerous legislators and other stakeholders have long been pushing for: PBM reform.

    Depending on whom you ask, the omission either represents a temporary setback or a sign that it will be a long time before any federal legislation passes that successfully alters major PBMs’ much-criticized business practices.

    “There’s still incredible bipartisan, widespread support for action on these issues,” says Joe Shields, managing director of Transparency-Rx, a coalition of smaller PBMs pushing for reform measures targeting their industry-dominant rivals. “We expect there will be action on these issues; that action could be in a matter of weeks, at least from what I’m hearing of some cadence coming out of Capitol Hill.”

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