Radar on Drug Benefits

In what is only the latest sign that PBM clients are growing increasingly disillusioned with the status quo, Minnesota-based insurer UCare recently chose Navitus Health Solutions, LLC as its new PBM partner — ending a relationship with The Cigna Group’s Express Scripts that had been in place since 2010.

“I think that there is a growing desire amongst employer groups and health plans to look at alternative options besides what we consider to be the big PBMs,” Patrick Mitsch, vice president of pharmacy at UCare, tells AIS Health, a division of MMIT. “There’s different value propositions that a PBM like Navitus can bring to the market that the Big Three just can’t,” he adds, referring to Express Scripts, CVS Health Group’s Caremark, and UnitedHealth Group’s Optum Rx, which control roughly 80% of the pharmacy benefits market.

The Institute for Clinical and Economic Review (ICER) published a report on Oct. 2 evaluating the blood thinners Eliquis (apixaban) and Xarelto (rivaroxaban), two of the 10 drugs that will be subject to Medicare price negotiations starting in 2026.

Based on ICER’s modeling and review of the available evidence, the organization determined that Eliquis and Xarelto could have substantial price premiums over warfarin. However, when compared with dabigatran, ICER noted that Eliquis could have a smaller price premium and Xarelto could have no price premium. Warfarin and dabigatran are both generic drugs that are competitors to Eliquis and Xarelto.

In a recent report, the Pharmaceutical Care Management Association (PCMA), the trade group representing the largest PBMs, claimed that employers often choose spread pricing when they set up their PBM contracts. But employer plan sponsor groups, which have pushed for years for a federal ban on spread pricing, tell AIS Health that the way PCMA describes employers’ pharmacy benefit options is misleading — instead, the plan sponsor groups say, PBMs manipulate employers into spread pricing arrangements.

PBMs are under intense scrutiny in Congress: Legislators from both parties seem likely to pass more aggressive regulation of the industry this year. A ban on spread pricing is one of the key policies under consideration. Spread pricing is the business practice in which PBMs pay pharmacies dispensing a drug less than what they charge payers, with the PBM pocketing the difference. This can result in substantial revenue for the PBM, as the “spread” for the same pharmaceutical product can vary widely from pharmacy to pharmacy.

The stand-alone Prescription Drug Plan (PDP) market — which was already in decline — is poised to take even more hits due to regulatory and legislative changes that are taking effect in 2024 and beyond, according to industry observers. Indeed, one expert who analyzed data from CMS’s 2024 Medicare Advantage and Part D “landscape files” predicts that “a lot of people are faced with pretty significant premium increases” next year.

There’s a complicated calculus driving that trend, explains Tom Kornfield, a senior consultant at Avalere Health. But both he and equities analyst George Hill agree that the Inflation Reduction Act of 2022 (IRA) is a major factor.