Radar on Drug Benefits

Health insurers and PBMs are paying pharmacies low rates — from one cent to $10 — for filling prescriptions of COVID-19 drugs Paxlovid and molnupiravir, The Wall Street Journal reports. Those fees often don’t cover the costs of filling prescriptions for the Pfizer Inc. and Merck & Co. drugs, pharmacists say, and thus some are refusing to stock the pills. The National Community Pharmacists Association is also lobbying CMS to recommend a $40 reimbursement rate for Paxlovid and molnupiravir, similar to what Medicare pays pharmacies for administering the COVID-19 vaccine, according to the article.

A Phase III clinical trial of AstraZeneca and Daiichi Sankyo drug Enhertu (trastuzumab deruxtecan) delivered promising results that could position the therapy to become a standard treatment for a large group of breast cancer patients. In a Feb. 21 press release, the drug companies reported that Enhertu prolonged survival and slowed the progression of metastatic breast cancer with low levels of a protein known as HER2. The improvement was “clinically meaningful” when compared with standard chemotherapy, and this is the first time such a therapy has shown a benefit in breast cancer patients who have low levels of HER2 expression — a group comprising 55% of all breast cancer patients — the drugmakers said. 

While the cost-saving potential of biosimilars was an overarching theme as the major PBMs’ parent companies discussed second-quarter 2021 earnings, “specialty” was the buzzword during the most recent round of conference calls regarding fourth-quarter and full-year 2021 financial results.

“I would definitely say that the specialty [pharmacy] and home delivery business are contributing to earnings and our margin,” said Heather Cianfrocco, CEO of UnitedHealth Group-owned PBM OptumRx, during a Jan. 19 call with anal

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.”