Radar on Drug Benefits

Last year, the main trade groups representing PBMs and drug manufacturers both broke records for money spent on lobbying. Industry experts say that isn’t unexpected, since policymakers’ ongoing focus on lowering prescription drug prices has put pressure on multiple players in the supply chain. But only PBMs, so far, have been able to keep federal reform measures at bay.

 “There’s a lot going on, so it doesn’t surprise me at all that they’re spending a lot on lobbying,” says Matthew Fiedler, a senior fellow with the Brookings Institution’s Center on Health Policy. Not only is the Inflation Reduction Act (IRA) still being implemented, but “we’re in the midst of the ongoing debate on PBM reform on the Hill,” which affects both PBMs and pharmaceutical companies, Fiedler tells AIS Health, a division of MMIT.

Medical professionals with track records of spreading vaccine misinformation are among HHS Secretary Robert F. Kennedy Jr.’s eight new appointments to the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP).

The new appointments came June 11, just two days after Kennedy announced he was retiring all 17 members of the panel that helps determine which vaccines are covered and reimbursed in the U.S.

Kennedy said the new members will attend ACIP’s late June meeting in the announcement made via the social media platform X.

GoodRx on June 9 launched a program that allows independent pharmacies to directly contract with the California-based company best known for its prescription discount platform. The GoodRx Community Link program leverages a cost-plus pricing model based on National Average Drug Acquisition Cost (NADAC) “to provide predictable pricing and favorable economics” to independent pharmacies that are facing “complex reimbursement models and competitive pressures,” the company stated. The press release also noted that entering into a direct agreement with GoodRx “does not waive a pharmacy’s right to participate in ongoing litigation against GoodRx,” referring to a lawsuit filed against the company and four major PBMs that accuses them of colluding to suppress reimbursement to independent pharmacies. GoodRx also said that starting July 1, all independent pharmacies will be opted out of its Integrated Savings Program by default, and those that sign a direct contract with GoodRx can opt into the ISP as an added benefit.

A survey from the Pharmaceutical Strategies Group (PSG) released on June 10 found that 90% of health plans and employers were moderately or very concerned about the affordability of GLP-1 medications for obesity, up 10% from last year’s report. The cost is not the only issue, though, as 42% of respondents that do not currently cover the medications said they would not cover them for obesity at any price.

Morgan Lee, Ph.D., PSG’s senior director of research and strategy, says the findings suggest that many payers still have questions about the best way to treat obesity even though the American Medical Association recognized obesity as a disease in 2013.

When deciding how to cover Stelara (ustekinumab) and its recent spate of follow-on products, prominent PBMs and payers are favoring Biocon Biologics Ltd.’s Yesintek and their own private-label biosimilars — including one that has been the target of litigation.  

Cigna Healthcare, a division of The Cigna Group, on May 15 issued a new drug-coverage policy that prefers branded Stelara, Yesintek, Alvotech/Teva’s Selarsdi and ustekinumab-ttwe, a biosimilar manufactured by Cigna subsidiary Quallent Pharmaceuticals. 

As nonpreferred products, Cigna’s new policy lists Formycon/Fresenius’ Otulfi, Celltrion’s Steqeyma and Sandoz/Samsung’s Pyzchiva. Regarding Pyzchiva, the policy notes that patients will instead be “directed to ustekinumab-ttwe,” Quallent’s unbranded version of the drug.