Radar on Drug Benefits

Optum Rx, the PBM owned by UnitedHealth Group, recently launched new programs that will reimburse community pharmacies for helping vulnerable and underserved patients access critical health care services. The move comes as major PBMs like Optum Rx are facing ever-increasing scrutiny for their business practices — including from rural and independent pharmacies that contend big PBMs are driving them out of business.  

A trade group for community pharmacists and a health policy expert both say that the programs have promise, although they also say it’s unclear how big of an impact Optum Rx’s initiatives will ultimately make. 

Although health plans’ formularies have largely been making it easier for people to access buprenorphine in recent years, new research indicates that coverage barriers and access gaps remain — particularly for a newer, costlier extended-release formulation of the opioid use disorder (OUD) drug.  

However, a recent FDA approval could usher in more competition that decreases the price and increases coverage of extended-release buprenorphine, which has major advantages over the immediate-release versions, according to one of the study authors. 

In 2021, almost all commercial, Medicare Advantage and Medicaid health plans covered at least one immediate-release buprenorphine, a medication for treating opioid use disorder (OUD), according to a recent Health Affairs study. Also, since 2017, fewer health plans have been requiring prior authorization and quantity limits for those medications.

However, fewer than half of commercial formularies and one-fifth of MA formularies covered extended-release buprenorphine products in 2021. Comparatively, 82.8% of Medicaid formularies covered such medications, and the share of Medicaid formularies without prior authorization requirements increased from 6.8% in 2018 to 63.3% in 2021. 

Merck & Co., Inc. filed a lawsuit on June 6 against the federal government, seeking to halt provisions in the Inflation Reduction Act (IRA) related to Medicare drug price negotiations. The suit, filed in the U.S. District Court for the District of Columbia, is the first involving a pharmaceutical company challenging that part of the IRA. Starting in 2026, the government for the first time will negotiate the price of certain high-cost medications that are not subject to generic or biosimilar competition. Merck contends in its lawsuit that the drug price negotiation program “is a sham” and “is tantamount to extortion” and violates the First and Fifth amendments to the U.S. Constitution. 

A Massachusetts resident last month sued CVS Health Corp. for using an artificial intelligence (AI) platform during a job interview, the Boston Globe reported. In the class-action lawsuit, Brendan Baker alleged CVS’s use of the HireVue AI system to assess job candidates’ honesty violated Massachusetts law, which forbids employers from using a polygraph or similar tests as a condition of employment. Companies such as T-Mobile and Delta Airlines have used HireVue. 

In a new regulation released on  May 23, the Biden administration proposed increasing drug price transparency reporting by PBMs and pharmaceutical manufacturers supplying Medicaid — and requiring Medicaid managed care organizations to remove pharmacy benefit administration costs from medical loss ratio (MLR) reporting. Experts say the proposed rule is a marginal but meaningful step forward in prescription drug cost containment, but they add that the proposed rule won’t do as much as bills under serious discussion in Congress to rein in controversial PBM business practices such as spread pricing.

The proposed rule, which CMS says in a fact sheet “implement[s] new statutory authorities included in the Medicaid Services Investment and Accountability Act of 2019,” is meant to improve the Medicaid Drug Rebate Program by “proposing new policies that would assure greater consistency and accuracy of drug information reporting, strengthened data collection, and efficient operation of the MDRP.” Per the fact sheet, notable elements of the regulation include: