Radar on Drug Benefits

The Big Three PBMs — Cigna Corp.’s Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health Corp.’s Caremark — once again added new drugs to their formulary exclusion lists for the 2022 plan year, but the rate of new exclusions slowed. Industry insiders tell AIS Health, a division of MMIT, that the slowing amount of exclusions indicates the PBMs find high value in opaque, complex contracting agreements with providers, even though certain preferences in areas like insulins, specialty drugs and biosimilars defy the logic of list prices.

According to an analysis of plan documents by Adam Fein, Ph.D., CEO of the Drug Channels Institute, Caremark now excludes 433 products from its formularies, Express Scripts excludes 485 and OptumRx excludes 492. Each amount sets a record number of exclusions for each company.

The manufacturers of four treatments aimed at easing the disease burden of mild-to-moderate COVID-19 received good news recently when the Institute for Clinical and Economic Review (ICER) determined in a draft report that their prices are “reasonably aligned with patient benefits.”

Each of the treatments — molnupiravir, Paxlovid and fluvoxamine, which are delivered orally, and the IV-administered sotrovimab  — have been shown in clinical trials to greatly reduce the risk of hospitalization or death in comparison to placebo treatments, according to a draft evidence report released Feb. 3 by ICER.

Pharmaceutical distribution and wholesaling giant Cardinal Health Inc. is optimistic that biosimilars will be broadly adopted and deliver big cost savings to the U.S. health care system in the next several years. The findings of a new white paper from the company run counter to more pessimistic predictions by other industry insiders, but Cardinal executives tell AIS Health, a division of MMIT, that even though some barriers to biosimilars remain, new approvals and regulatory changes have already accelerated adoption.

“I am deeply encouraged by the progress made in the U.S., especially this past year,” Sonia Oskouei, Cardinal Health’s vice president for biosimilars, wrote in the report. “Following the launch of the first biosimilar in 2015, we now have 33 FDA approved biosimilars with 21 available on the market as of January 2022. The U.S. biosimilars story that was initially described as sluggish and delayed has now transformed to one of progress and momentum. This past year, the promise of biosimilars has started to become a reality, as greater competition for some of the costliest biologic treatments on the market is beginning to drive meaningful cost savings.”

Mark Cuban Cost Plus Drug Company (MCCPDC) launched its online, generic-dispensing pharmacy on Jan. 19, becoming the latest entrant into a burgeoning market of prescription drug retailers that operate independent of traditional pharmacy benefits. Health care insiders say that the amount of activity in the emerging segment is encouraging, but they add that no one player is likely to become dominant in the space.

MCCPDC, a discount prescription drug startup launched by venture capitalist and Dallas Mavericks owner Mark Cuban, now operates an online pharmacy that sells directly to consumers and does not accept insurance. MCCPDC CEO Alex Oshmyansky, M.D., Ph.D., told AIS Health, a division of MMIT, in October that the firm is registered as a pharmaceutical wholesaler with the FDA.