Radar on Drug Benefits

Over the next few years, numerous biosimilars are expected to hit the U.S. market, leading to more competition and potentially lower costs for some expensive medications. However, that will not be enough to offset the entrance of new high-cost drugs and expanded indications for specialty medicines, according to the latest Pharmaceutical Strategies Group (PSG) “Spend and Trend” report.

The analysis, published on July 25, found that the per member per year (PMPY) cost for specialty drugs was $1,169 in 2022, a 14.1% increase from the previous year. After factoring in rebates, the PMPY increased by 12.5%, from $822 in 2021 to $925 in 2022.

PSG projects that the pre-rebate and post-rebate PMPY in 2025 will be $1,712 and $1,370, representing a 46.5% and 48.5% increase from last year, respectively.

In its latest drug pipeline insights report, Optum Rx pivots from its habit of highlighting upcoming medications for rare diseases, instead focusing on a trio of emerging therapies that target much wider patient populations. The UnitedHealth Group-owned PBM tells AIS Health, a division of MMIT, that the move was driven more by happenstance than intention.

“In this report, we were focusing on drugs expected in the third quarter of 2023, and from among that group, these three seemed particularly interesting to describe in more detail,” explains Bill Dreitlein, senior director of pipeline and drug surveillance at Optum Rx.

The Federal Trade Commission doesn’t want to hinder state and federal government efforts to reform pharmacy benefit managers as it continues its investigation of possible anti-competitive business practices in the industry.

With that in mind, the commission unanimously adopted a position statement July 20 that “cautions against reliance on certain of its prior advocacy statements and reports relating to the pharmacy benefit manager market.”

The three commissioners on the panel are Democratic appointees. Whether the vote would have been any different with a Republican presence on the commission is unclear, however. The FTC agreed last year to launch its broad investigation into the PBM industry with the support of two Republican commissioners. 

The large markups that hospital outpatient departments (HOPDs) place on biologic medicines are both causing plan sponsors’ costs to soar and muting the potential savings that could come from biosimilars, according to a new report from the Employee Benefit Research Institute (EBRI). One of the report’s coauthors says that health care provider consolidation is largely the culprit — and it’s an issue that plan sponsors may struggle to combat.

While physician practices also mark up the prices of provider-administered drugs, HOPDs generally raise them even more, explains Paul Fronstin, Ph.D., director of health benefits research at EBRI. “And that’s because they’ve got purchasing power, and the purchasing power is increasing as they acquire more and more physician practices,” he adds.

A new study from the Employee Benefit Research Institute highlights the high — and growing — markups that hospital outpatient departments assign to biologic drugs, while also examining the variation in how HOPDs and physician offices (POs) treat innovator biologics compared to their biosimilars.

The study analyzed medical and pharmacy claims data from Merative MarketScan Commercial Database — which covers nearly 25 million people with private health insurance — from 2013 to 2020, and it focused on seven innovator biologics and their biosimilars that had been launched as of 2020.