Radar on Drug Benefits

Since the FDA approved Journavx (suzetrigine) earlier this year for moderate to severe acute pain, a few payers have announced they would cover the medication, which offers an oral, non-opioid option for people who are at risk of developing opioid use disorder (OUD). Although Journavx’s list price is more than 20 times higher than some generic opioids, David Rind, M.D., chief medical officer at the Institute for Clinical and Economic Review (ICER), says the new medication has a “completely reasonable price” and is “almost certainly high value.”  

Rind adds that ICER “almost always” recommends that pharmaceutical companies “should discount their prices.” However, in this case Rind says that Vertex Pharmaceuticals, Journavx’s manufacturer, “should be commended for fair pricing.” Journavx has a wholesale acquisition cost of $15.50 per tablet or $232.50 for a weekly regimen of two pills per day, which is significantly below ICER’s cost-effectiveness threshold of $4,500 to $6,500 per week. Rind notes that generic opioids cost about $10 per week.  

The “hottest topic” in health policy is also the one that is “ripe with perverse incentives” that can enrich companies: the 340B program, according to panelists at the 2025 Academy of Managed Care Pharmacy (AMCP) conference, held March 31 through April 4 in Houston. 

“We can argue about the purpose and the intent of the program all day, but nobody is going to say that the purpose of 340B was to benefit plans and PBMs,” said Alan Arville, member of law firm Epstein Becker Green. 

Established by statute in 1992, the 340B program allows covered entities that serve uninsured and low-income patients, such as safety net hospitals, to purchase drugs from manufacturers at steep discounts for outpatient use. Covered entities can stretch their resources to provide more services to vulnerable populations. Providers covered by 340B can pass the discounts to patients at the pharmacy counter or pocket the savings. They can also dispense the medications at a higher cost to the patient or the patient’s insurance. 

The Alabama House of Representatives on April 8 unanimously voted in favor of a bill to require PBMs to reimburse independent pharmacies at a rate that is at least equal to the Medicaid rate for medications, the Associated Press reported. The vote occurred shortly after the Alabama Senate voted to advance the legislation, which will now go to Gov. Kay Ivey (R). When the “Community Pharmacy Relief Act” was passed by the state Senate in March, Democratic state Sen. Bill Beasley, who is a retired pharmacist and sponsored the bill, said it was necessary to prevent pharmacy closures. “We’re losing almost one drugstore per week, going out of business because they are paid such a small amount of money from the PBM industry to fill prescriptions for their patients at their drugstore,” Beasley said, according to the Alabama Reflector. 

A year after it was enacted, Florida’s PBM reform law is causing compliance headaches for employers and PBMs alike. 

The Prescription Drug Reform Act (PDRA), which took effect in January 2024, requires PBMs to eliminate spread pricing and pass 100% of manufacturer rebates to plan sponsors, and it forbids requiring enrollees to fill medications by mail order, among other provisions. But the law also requires employers to submit a one-page attestation acknowledging that the PBM is complying with the law — a requirement that can place a substantial burden on employers. 

What’s more, Florida’s Office of Insurance Regulation (OIR) in February requested large amounts of sensitive patient data from PBMs, Bloomberg first reported. The request includes information on all prescriptions filled in Florida in 2024, even by nonresidents, including patient names and medications, raising serious privacy concerns. 

A Minnesota district court judge on March 24 dismissed a lawsuit brought last year by former Wells Fargo & Co. employees alleging the company violated the Employee Retirement Income Security Act (ERISA) by paying more than it should have for prescription medications. The ruling occurred two months after a district court judge in New Jersey dismissed similar claims that a Johnson & Johnson employee made against her employer, saying she lacked standing to bring the case. 

However, the plaintiff in the Johnson & Johnson case on March 10 filed an amended complaint with the court and added another plaintiff. The re-filing “enhanced the allegations with respect to what the harm is to the plaintiff,” says Joanne Roskey, an attorney with Miller & Chevalier who is not involved with the case. Roskey expects Johnson & Johnson to seek another motion to dismiss in the next few weeks challenging the amended allegations.