Radar on Drug Benefits

As of 2023, about 50.5 million Medicare beneficiaries are enrolled in a plan with Part D prescription drug coverage, with 44% in stand-alone Prescription Drug Plans (PDPs) and 56% in Medicare Advantage Prescription Drug Plans (MA-PDs), according to a KFF analysis.

The three largest Part D insurers by market share — UnitedHealth Group, CVS Health Corp. and Humana Inc. — account for 57% of enrollment in 2023. More than half of UnitedHealth’s and Humana’s Part D enrollees chose MA-PDs, while the majority of CVS Health, Centene Corp. and The Cigna Group Part D enrollees are in PDPs.

The CDC announced on Nov. 16 that it had made available more than 77,000 additional doses of Beyfortus (nirsevimab-alip), a monoclonal antibody intended to protect infants from severe respiratory syncytial virus (RSV) disease. Since the FDA approved Beyfortus in July, there have been supply issues and insurance coverage limitations for RSV medications. Sanofi, which manufactures Beyfortus alongside AstraZeneca, noted last month that it had seen “an unprecedented” level of demand for the medication and that it was working with the CDC to distribute more doses through the agency’s Vaccines for Children program.

CMS has delayed its plan to cover Medicare patients’ full cost of preexposure prophylaxis (PrEP) using FDA-approved antiretroviral drugs to prevent HIV infection in high-risk patients, according to KFF. CMS had announced the proposal in July and expected to make it official on Oct. 10, but KFF said the delay has occurred while CMS “is still working out details on how to transition coverage for patients already taking the drugs.” The drugs can cost more than $20,000 per year in the U.S.

In its annual assessment of whether prescription drug formularies overly restrict access to select medications, the Institute for Clinical and Economic Review (ICER) gave insurers high marks. While it acknowledges that coverage policy information needs to be much more transparent, this year’s report concludes that “major payer coverage policies for 18 drugs often met fair access criteria for cost sharing, clinical eligibility, step therapy, and provider restrictions.” 

However, ICER President-Elect Sarah Emond says the nonprofit research institute is fully aware that its analysis can only do so much to examine all the myriad, complicated facets of what truly defines “fair access.” Therefore, she adds, ICER is actively working on how to make future reports more comprehensive.  

The Senate Finance Committee on Nov. 8 unanimously approved legislation to block pharmacy benefit manager practices that result in higher cost-sharing for beneficiaries.

The bill does not include provisions that were included in an earlier draft that would ensure “high discount” biosimilars get favorable formulary tiering. But those policies may be added back before the bill reaches the Senate floor for a vote.

The committee is planning to combine the bill with other PBM reform legislation it approved in July which includes a policy that would de-link PBM compensation from the list price of drugs. 

The Big Three PBMs — The Cigna Group’s Express Scripts, UnitedHealth Group’s Optum Rx and CVS Health Corp.’s Caremark — all delivered positive results during the third quarter of 2023, and in some ways helped offset underperformance for the firms’ health benefits businesses.

Wall Street analysts were generally positive about the performance of the firms’ PBM subsidiaries, but they had questions about the way each firm plans to manage the cost of glucagon-like peptide 1 (GLP-1) agonists for their clients.