Radar on Drug Benefits

UnitedHealth Group has promoted Patrick Conway, M.D., to CEO of Optum Rx, the company’s PBM. Conway revealed the new role in a LinkedIn post. He was previously the CEO of Care Solutions at Optum, UnitedHealth’s health care services division. Heather Cianfrocco, Optum Rx’s CEO, is now the president of Optum. Before coming to UnitedHealth, Conway served as CEO of Blue Cross Blue Shield of North Carolina and as director of the Center for Medicare and Medicaid Innovation.

Mark Cuban Cost Plus Drug Co. has formed a partnership with Scripta Insights, a health care software company that works with health plans and self-insured employers to lower pharmacy benefit costs. Scripta plans on integrating the Mark Cuban company’s discounted pricing into its Med Mapper product. Alex Oshmyansky, CEO of Mark Cuban Cost Plus, said the companies “share a common goal of providing consumers the lowest possible price for their prescription medications.” The Mark Cuban company primarily sells generic medications at a discount, but earlier this year it began offering brand-name drugs from Janssen, a division of Johnson & Johnson Co., and IBSA Institut Biochimique SA, a pharmaceutical company based in Switzerland.

Two congressional committees advanced notable PBM legislation, moving one step closer toward comprehensive changes to PBMs’ dominant business model.

The Senate Finance Committee, with a near-unanimous bipartisan majority, advanced a major Medicare- and Medicaid-focused PBM reform bill on July 26. D.C. insiders tell AIS Health, a division of MMIT, that the committee’s move bodes well for notable commercial market PBM reforms. So does the fact that senators of both parties are emphatically in favor of it, despite reluctance by some Republican members of the House of Representatives to make aggressive changes to PBM regulations.

Over the next few years, numerous biosimilars are expected to hit the U.S. market, leading to more competition and potentially lower costs for some expensive medications. However, that will not be enough to offset the entrance of new high-cost drugs and expanded indications for specialty medicines, according to the latest Pharmaceutical Strategies Group (PSG) “Spend and Trend” report.

The analysis, published on July 25, found that the per member per year (PMPY) cost for specialty drugs was $1,169 in 2022, a 14.1% increase from the previous year. After factoring in rebates, the PMPY increased by 12.5%, from $822 in 2021 to $925 in 2022.

PSG projects that the pre-rebate and post-rebate PMPY in 2025 will be $1,712 and $1,370, representing a 46.5% and 48.5% increase from last year, respectively.

In its latest drug pipeline insights report, Optum Rx pivots from its habit of highlighting upcoming medications for rare diseases, instead focusing on a trio of emerging therapies that target much wider patient populations. The UnitedHealth Group-owned PBM tells AIS Health, a division of MMIT, that the move was driven more by happenstance than intention.

“In this report, we were focusing on drugs expected in the third quarter of 2023, and from among that group, these three seemed particularly interesting to describe in more detail,” explains Bill Dreitlein, senior director of pipeline and drug surveillance at Optum Rx.

The Federal Trade Commission doesn’t want to hinder state and federal government efforts to reform pharmacy benefit managers as it continues its investigation of possible anti-competitive business practices in the industry.

With that in mind, the commission unanimously adopted a position statement July 20 that “cautions against reliance on certain of its prior advocacy statements and reports relating to the pharmacy benefit manager market.”

The three commissioners on the panel are Democratic appointees. Whether the vote would have been any different with a Republican presence on the commission is unclear, however. The FTC agreed last year to launch its broad investigation into the PBM industry with the support of two Republican commissioners.