Radar on Drug Benefits

CVS Health Corp. said on Jan. 6 that all commercial prescriptions dispensed through CVS Pharmacy are now contracted through the company’s CostVantage reimbursement model. The company aims to increase transparency for patients and PBMs alike with the new model, but some industry experts are greeting the announcement with a dose of skepticism. 

CVS said in addition to routing all commercial prescriptions through CostVantage, it is working with CMS to eventually include Medicare and Medicaid prescriptions. Reimbursement through CostVantage is based on the underlying cost of a drug plus a “defined markup” and a dispensing fee “tied to the care and value we provide.” 

CVS Health Corp.-owned Aetna filed a lawsuit on Dec. 30 against several pharmaceutical manufacturers, alleging they engaged in price-fixing. The insurer is seeking damages it incurred “from egregious overcharges it paid for certain widely used generic drugs, arising from a far-reaching conspiracy among Defendants and others to blatantly fix the price of such drugs,” according to the lawsuit, which was filed in Superior Court in Hartford, Connecticut. Aetna wrote that the “conspiracy…infected the entire generic marketplace” and “was designed to evade detection.” The alleged scheme, according to the lawsuit, involved the companies working together to dissuade competition and assign certain manufacturers to specific markets. 

Amgen Inc. has chosen Optum’s new biosimilars-focused private-label subsidiary, Nuvaila, to be the sole distributor of Wezlana (ustekinumab-auub), the first Stelara biosimilar, AIS Health’s Radar on Specialty Pharmacy reports. The new interchangeable biosimilar launched on Jan. 1. It is approved for all of Stelara’s indications and is available in subcutaneous and intravenous formulations. At least seven more Stelara biosimilars are expected to launch after Wezlana. Stelara is approved for treating patient who are at least 6 years old with moderate-to-severe plaque psoriasis and who are candidates for phototherapy or systemic therapy; patients who are at least 6 years old with active psoriatic arthritis; adults with moderately to severely active Crohn’s disease; and adults with moderately to severely active ulcerative colitis. 

In a development that sparked frustration among some industry stakeholders, an agreement to pass a government spending bill that contained significant PBM reforms collapsed late last week. Congress ultimately passed a pared-down spending bill just in time to avert a government shutdown, but that left PBM critics wondering when reform policies with bipartisan backing will ever make it into law.

“Probably late Wednesday, it looked like it was in and a done deal, and then the entire package…fell apart,” lamented Joe Shields, managing director of Transparency-Rx.

Two House Republicans recently requested documents from CVS Health Corp., saying they are investigating whether the company’s Caremark PBM engaged in anticompetitive practices by barring independent pharmacies from participating in specialty pharmacy hubs, also referred to as pharmaceutical hubs. But some experts question the move, noting there is little indication that CVS is engaging in this practice.

House Judiciary Committee Chair Jim Jordan (R-Ohio) and Rep. Thomas Massie (R-Ky.) on Dec. 12 sent a letter to CVS CEO David Joyner, requesting documents and communications from Caremark to independent or specialty pharmacies related to pharmacy hubs. Jordan’s concern is that Caremark is preventing independent pharmacies from participating in “innovative” arrangements that could save money for customers, by threatening to kick pharmacies out of Caremark’s network if they participate in such an arrangement.

Most major commercial payers provided fair access to a sample of prescription medications, according to a recent review from the Institute for Clinical and Economic Review (ICER). Sarah Emond, ICER’s president and CEO, tells AIS Health that payers “should be given a lot of credit for being in line with a lot of the criteria that we’ve established.” However, she cautions it is difficult to assess how payers implement the written policies in a real-world setting.

ICER’s fourth annual “Barriers to Fair Access” report, published on Dec. 19, assessed coverage policies associated with 11 medications that the nonprofit organization evaluated for cost-effectiveness in 2022. The authors identified the 10 largest commercial payers in the U.S. and selected those insurers’ largest formularies based on the number of covered lives. They obtained the formulary data from MMIT, AIS Health’s parent company, which also provided information on coverage policies if the payer did not share them with ICER.