Radar on Drug Benefits

  • 2023 Drug Trends Included GLP-1s, Humira Biosimilars, $0 Cost Share

    Notable pharmacy benefit trends in 2023 claims data included increased use of GLP-1s for weight loss, shifting market dynamics amid high demand for AbbVie Inc.'s Humira (adalimumab) and its biosimilar competitors and increasing approval of expensive gene therapies. All this took place amid “persistent price inflation” across most drug categories, according to a new report by PBM analytics firm Xevant.

    According to Xevant’s 2023 Drug Trend Report, which analyzed pharmacy claims data from its commercial plan clients, 2023 plan-paid amounts across all brand and generic non-specialty and specialty drugs went up an average of 20% from 2022. In addition, the number of specialty prescriptions processed by plans increased by 11% in 2023. GLP-1 utilization increased by 400%, while claims for Humira and its biosimilars increased by 25%.

  • Part D Plans Get Ready for Potentially ‘Messy’ Rollout of M3P Program

    For the first time ever, Medicare Part D beneficiaries in 2025 will have the opportunity to spread their prescription drug expenses over the course of the plan year. While Part D sponsors must offer the option to enrollees effective Jan. 1, 2025, plans face multiple considerations and tasks prior to then. One of their most immediate concerns, industry experts say, is factoring in potential administrative costs and/or financial losses associated with the new Medicare Prescription Payment Plan (M3P, as many are calling it) into bids due next month.

  • Remote Physiologic Monitoring Use Among Medicaid Enrollees Skyrocketed From 2019 to 2021

    Between 2019 and 2021, the use of remote physiologic monitoring (RPM) via wearable devices and mobile applications soared by more than 1,300% among Medicaid enrollees, which was driven by a small number of providers, according to a recent Health Affairs study.

    Based on Transformed Medicaid Statistical Information System Analytic Files data from Jan. 1, 2019, to Dec. 31, 2021, the study found that the number of RPM recipients per 100,000 Medicaid enrollees increased from 2.1 recipients in 2019 to 29.6 recipients in 2021 and started to accelerate with the March 2020 onset of the COVID-19 public health emergency. Among over 5,600 distinct providers who billed RPM claims for Medicaid enrollees in 2021, more than half of the claims were from 5% of providers.

  • News Briefs: Optum Rx Unveils New Pricing Model Starting in 2025

    Optum Rx announced on May 20 a new program, Clear Trend Guarantee, that will combine guarantees into a single per member cost metric. The PBM will make Clear Trend Guarantee available to plan sponsors starting on Jan. 1, 2025. In a press release, Optum Rx described Clear Trend Guarantee as “an alternative, guarantee-based pricing model that combines retail, home delivery, specialty drug and rebate components into one per member guarantee” and said the program would “ultimately deliver value to individuals and families who want predictability in their premiums and drug costs.” Meanwhile, Patrick Conway, Optum Rx’s CEO, wrote in a May 22 LinkedIn post that Clear Trend Guarantee “means plan sponsors will have another option to manage their pharmacy spend with greater predictability and choice to help manage lowest net cost.” Optum Rx last year announced other alternative pricing models, including a pass-through model using average ingredient costs.
  • PBMs’ 1Q Earnings Calls Are All About Biosimilar, GLP-1 Programs

    During their first-quarter earnings calls, the companies that own the three largest PBMs shared a wealth of details about how the market is responding to their new programs targeting GLP-1 and biosimilar drugs. Wall Street analysts noted that those remarks offered a welcome highlight amid decidedly mixed results in the firms’ health insurance divisions.

    The Cigna Group CEO David Cordani opened his prepared remarks during the company’s May 2 earnings call by spotlighting the company’s “focus on biosimilars to drive greater affordability,” calling it one of Cigna’s key strategic growth drivers.

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