Radar on Drug Benefits
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Novel Therapies Take Center Stage in Optum Rx Drug Pipeline Report
In its latest report highlighting notable drugs nearing FDA approval, UnitedHealth Group’s Optum Rx PBM singles out two therapies designated as orphan drugs and one that has been granted priority review. Experts tell AIS Health that payers deciding how to cover these drugs will undoubtedly have to weigh factors such as a high unmet need for treatment, the durability of patients’ response to the therapy, and potentially high price tags.
For example, regarding the only non-orphan drug included in the report, Apellis Pharmaceuticals, Inc.’s pegcetacoplan, there are currently no other approved treatments for the condition it’s targeting, “so that will have an impact on how payers approach coverage,” says Bill Dreitlein, senior director of Pipeline & Drug Surveillance at Optum Rx.
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End of Government Purchasing, PHE Could Lead to Access, Pricing Issues for COVID Treatments
Since the COVID-19 pandemic began, the federal government has spent tens of billions of dollars purchasing vaccines, treatments and tests and providing them for free to the public. Congress has also passed legislation ensuring private and public payers cover those countermeasures for as long as the public health emergency (PHE) is in place.
However, that may soon be ending as Congress has yet to authorize additional COVID-specific funding and the PHE is likely to expire sometime next year. That could lead to questions about access, pricing and insurance coverage, according to panelists who spoke during a Kaiser Family Foundation (KFF) webinar on Oct. 19.
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Prescription Drug Spending Increases 16% Over Five Years, Driven by Rising Drug Prices
Total inflation-adjusted spending on prescription drugs grew from $520 billion in 2016 to $603 billion in 2021, before accounting for rebates, according to a report published by HHS’s Assistant Secretary for Planning and Evaluation (ASPE). Retail drug expenditures represented about 70% of prescription drug spending in 2021. For retail prescription drugs, there was a 13% increase in drug spending over the five years studied, yet only a 5.7% increase in the number of prescriptions.
Meanwhile, more and more Americans received their drugs from mail order pharmacies, clinics and home health care organizations between 2016 and 2021.
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News Briefs: Plans, PBMs Are Blocking Access to Birth Control
A congressional panel found that major PBMs and health insurers are charging members cost sharing and imposing other coverage requirements on birth control products in violation of the Affordable Care Act. The “investigation identified more than 30 birth control products for which most health insurers and PBMs reviewed impose cost-sharing requirements or coverage exclusions,” according to a press release. Among the companies examined were CVS Health Corp., UnitedHealth Group, Elevance Health Inc., Cigna Corp., Humana Inc. and Prime Therapeutics, a PBM owned by a consortium of Blues affiliates. “From 2015 to 2021, companies denied exceptions requests on average four or more times out of ten,” the press release added.
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Once Nonexistent, Pipeline for RSV Vaccines is Now Crowded With Contenders
For decades, a successful vaccine for respiratory syncytial virus (RSV) — which sends thousands of infants and older adults to the hospital each year — has remained elusive. Yet several heavyweight pharmaceutical companies are now poised to fill the void, as they’re nearing the finish line in the development of RSV vaccines that could ultimately comprise a multibillion-dollar market. Coverage of the new vaccines, according to an industry expert, will hinge on the all-important Advisory Committee on Immunization Practices (ACIP), which requires payers to fully reimburse any inoculation that it recommends.
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