Radar on Drug Benefits

Despite mostly lukewarm fourth-quarter 2024 results from their parent companies, CVS Health Corp.’s Caremark, The Cigna Group’s Express Scripts and UnitedHealth Group’s Optum Rx showed strong results and optimistic outlooks for 2025. 

The CEOs of those companies also fired back at PBM criticism, stating that PBMs are crucial to negotiating and keeping drug prices low. PBMs have faced pressure from both lawmakers and the public, including administrative complaints and lawsuits aimed at alleged price fixing and claims of contributing to the opioid epidemic. Federal lawmakers have also pushed for legislation to change PBM business practices and increase transparency — and could include PBM reform measures in a budget reconciliation bill as early as March. 

The National Community Pharmacists Association (NCPA) late last month joined in a class-action lawsuit against GoodRx and four major PBMs, alleging the companies are working together to suppress reimbursement to independent pharmacies. Meanwhile, NCPA CEO Douglas Hoey tells AIS Health that even as PBMs such as The Cigna Group’s Express Scripts tout initiatives to help with the plight of independent pharmacies, “PBMs are putting them out of business” with payments that are oftentimes below the cost of operating their pharmacies. 

The NCPA filed its lawsuit on Jan. 22 in the U.S. District Court’s Central District of California Western Division, the same jurisdiction as separate lawsuits filed last fall by Community Care Pharmacy, which is based in Michigan, and Keaveny Drug, a Minnesota-based pharmacy.  

If the new Congress agrees with some Republican lawmakers’ view that the Medicare Part D Premium Stabilization Demonstration is a “taxpayer-funded bailout” for health insurers, it can either defund the program or limit CMS’s authority to create such demonstrations in the first place, pointed out a recent report from the Congressional Research Service (CRS).  

However, one health policy expert says that any action regarding the controversial demonstration is more likely to come from CMS than from Congress. 

The Nevada Division of Insurance is seeking public comment on proposed updates to its essential health benefits benchmark plan, which would require Affordable Care Act exchange plans sold in the state to expand their prescription drug coverage. The Division of Insurance is considering selecting a new set of benefits to become its new benchmark plan and must seek public comment under CMS rules. The state is considering adding all FDA-approved drugs to treat opioid use disorder; all approved drugs to test, treat and prevent HIV; and all approved drugs to test, treat, and prevent hepatitis B and C. The deadline for submitting comments is March 9. 

A couple in Wisconsin filed suit against Walgreens and UnitedHealth Group’s Optum Rx PBM after their son’s death following a $500 surge in his asthma medication’s price. The Associated Press reported that Shanon and William Schmidtknecht filed the lawsuit a year after their 22-year-old son died of an asthma attack after he could not afford to refill his medication. The suit alleges the pharmacy and PBM did not give him advance notice that his out-of-pocket costs for Advair Diskus were increasing from $66 to $539. He suffered a fatal asthma attack several days later. They also claim the price was increased without a valid medical reason. 

Shortly after taking office, President Donald Trump on Jan. 20 rescinded numerous executive orders that were put in place under his predecessor, Joe Biden — including one that led to the introduction of three CMS drug pricing pilot programs. However, experts say it's still unclear what Trump’s move indicates for the future of the models.  

Biden issued his order in October 2022 to address lowering prescription drug costs through the CMS Center for Medicare and Medicaid Innovation (CMMI). In February 2023, CMMI announced three models under consideration, including the Cell and Gene Therapy (CGT) Access Model, the Accelerating Clinical Evidence Model and the Medicare $2 Drug List Model. The CGT model is the furthest along and is set to launch this year, while the other two models are still in the planning stages.