Radar on Drug Benefits

While an unprecedented number of Medicare Advantage Prescription Drug plans earned a 5-star rating for 2022 largely because of flexibilities granted during the COVID-19 public health emergency, Blue Cross & Blue Shield of Rhode Island (BCBSRI) credits a performance-based pharmacist intervention model with dramatically improving its drug-related scores and contributing to a 5-star summary rating for both of its contracts.

For 2022, CMS allowed plans to use the better of the two years’ rating (2021 or 2022) for most measures because all contracts qualified for the “extreme and uncontrollable circumstances policy.” Plans will not have that flexibility for the 2023 star ratings due out this fall.

Centene Corp. agreed to pay Washington $19 million to resolve allegations that it overcharged the state’s Medicaid program for pharmacy benefit management services. As part of the resolution, Centene will pay an additional $13 million to the federal government “for administration of Medicaid in Washington state,” according to a press release from Washington’s attorney general. The agreement with Washington is Centene’s 11^th such settlement with a state regarding how its PBM subsidiary Envolve administered pharmacy benefits in Medicaid.  

The public will likely need annual COVID-19 vaccinations in the future, similar to how the flu is treated, White House officials said during a recent press briefing. “It is becoming increasingly clear that, looking forward with the COVID-19 pandemic, in the absence of a dramatically different variant, we likely are moving towards a path with a vaccination cadence similar to that of the annual influenza vaccine, with annual, updated COVID-19 shots matched to the currently circulating strains for most of the population,” said Anthony Fauci, M.D., the president’s chief medical adviser. Ashish Jha, the White House’s coronavirus response coordinator, said the U.S. is able to pursue this strategy because it now has vaccines available that match the dominant strain circulating — a first since the pandemic started. However, some “vulnerable groups” might continue to need more frequent vaccination against COVID-19, Fauci said on Aug. 6.  

The FDA on Aug. 19 approved the first and only rapid-acting oral drug for major depressive disorder (MDD), a treatment that is being hailed by its manufacturer as a “potential game-changer” for people struggling with the difficult-to-treat condition. 

One pharma analyst expressed optimism about the drug’s ability to disrupt the MDD treatment market. However, experts from the PBM sector predict that payers may not embrace the drug warmly given how many generics are available to treat depression. 

The federal government will stop purchasing COVID-19 vaccines and therapeutics as soon as this fall, Biden administration officials said recently — meaning payers will have to procure vaccines and treatments like any other commercial pharmaceutical product. Health care experts tell AIS Health, a division of MMIT, that the move is likely to make vaccines and therapeutics less accessible and introduce dispensing costs that could drive up premiums. 

The Biden administration is transitioning away from the “acute emergency phase where the U.S. government is buying the vaccines, buying the treatments, buying the diagnostic tests. We need to get out of that business over the long run,” White House Coronavirus Response Coordinator Ashish Jha, M.D., said during an Aug. 16 event organized by the U.S. Chamber of Commerce.  

After the FDA approved Zynteglo (betibeglogene autotemcel) on Aug. 17, the gene therapy’s manufacturer, bluebird bio, Inc., announced the drug would have a $2.8 million wholesale acquisition cost (WAC). That is the highest WAC for a drug hitting the market in the U.S.  

Zynteglo is indicated as a potential cure for patients with transfusion-dependent beta-thalassemia, a rare disorder caused by genetic mutations in cells that carry oxygen throughout the body. Such patients typically require red blood cell transfusions every two to five weeks.