Radar on Drug Benefits

Almost two years after Paxlovid received emergency authorization as a treatment for acute COVID-19 infection, Pfizer Inc. and the U.S. government are now in the throes of transitioning the drug to the commercial market. That means the drugmaker is, in its own words, “working diligently with payers to achieve the best possible formulary placement” for Paxlovid — but also raising some eyebrows with the list price it set for the antiviral therapy.

Pfizer said in a statement that the commercial list price for Paxlovid (nirmatrelvir/ritonavir) in the U.S. will be $1,390 per five-day treatment course. That’s more than twice what the U.S. government paid for the drug, $529 per five-day course, and significantly higher than the price range of $563-$906 that the Institute for Clinical and Economic Review (ICER) suggested would be most cost effective.

Although PBMs are taking increasing heat for spread pricing — or charging payers more for a drug than pharmacies are reimbursed — they aren’t the only players in the drug supply chain that engage in the practice, a new study points out. And one of the study’s authors says its findings suggest that patients may be better off if generic drugs are simply removed from insurance coverage entirely.

The study, published in JAMA Health Forum on Oct. 20, examined data associated with 45 high-utilization Medicare Part D-covered generic drugs.

“Spread pricing is more of an issue for generic drug pricing than for branded drug pricing,” explains Ge Bai, Ph.D., one of the study's authors and a professor at Johns Hopkins University’s schools of business and public health.

After Blue Cross Blue Shield of Michigan implemented a five-day opioid prescribing limit in 2018, members who underwent general surgeries were prescribed and filled fewer prescriptions and had similar patient-reported outcomes compared with enrollees who had procedures before the program was initiated, according to a study published in JAMA Health Forum on Oct. 13.

James Grant, M.D., BCBS of Michigan’s chief medical officer, tells AIS Health, a division of MMIT, that the results show payers can steer people away from potentially addictive opioids without having a negative impact on their pain management.  

Only 2% of Medicare beneficiaries who enrolled in a stand-alone Prescription Drug Plan (PDP) in 2024 will be in contracts with 4 or more stars, compared to 42% in the 2022 plan year and 9% in 2023, according to CMS’s recently released estimates. The average Star Rating for PDPs dropped to 3.11 in 2024 from 3.70 in 2022, with two contracts receiving 1.5 stars.

The distribution change is largely fueled by methodology changes in how many of the Star Ratings are calculated. Known as Tukey outlier deletion, the changes center on removing outlier contract scores when determining the cut points for all non-Consumer Assessment of Healthcare Providers and Systems measures.

Amazon.com Inc. will deliver prescriptions via drone in College Station, Texas, the e-commerce giant said on Oct. 18. The online retailer said it will fill and deliver prescriptions for Amazon Pharmacy customers via drone in “60 minutes or less,” and that more than 500 medications can be delivered using the service. An Amazon press release claims that “Amazon’s drones have safely delivered hundreds of household items in College Station since December 2022.” Intermountain Health, the Utah-based integrated health system, has delivered prescriptions by drone since 2021 in the Salt Lake City area, the Associated Press reports.

Elevance Health Inc.’s CarelonRx PBM will add two of Boehringer Ingelheim’s Humira (adalimumab) biosimilars to some of its formularies starting Dec. 1, the firm said on Oct. 19. The move will put those drugs “at parity with Humira,” per a press release. The lower-list-price version of adalimumab-adbm  will be added to all CarelonRx’s commercial formularies, while Boehringer’s Cyltezo will be added to “select” commercial formularies, the press release added.