Spotlight on Market Access

In the seven years since the approval of the first chimeric antigen receptor T-cell (CAR-T) therapy, the agents have proved to be effective in the treatment of non-Hodgkin lymphoma. But the one-time-use agents come with risks, including the potentially fatal cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS), so the FDA requires patients remain near their treatment center for four weeks after administration, which can be onerous for patients. But a recent study finds that side effects were rare after the first two weeks post-infusion, perhaps helping lead to less of a burden for patients.

Premiums for many stand-alone Medicare Part D Prescription Drug Plans will go up moderately in 2025, while the number of PDP options for beneficiaries will drop significantly, according to AIS Health’s analysis of the recently released CMS Medicare Advantage and Part D landscape files.

The Inflation Reduction Act, passed in 2022, ushered in a host of policy changes to the Part D benefit that will take effect in 2025: Most notably, Medicare Part D beneficiaries’ out-of-pocket drug costs will be capped at $2,000 annually and Part D plan sponsors will be responsible for 60% (up from 20%) of any costs their enrollees incur beyond that cap. As a result, the Medicare Part D national average monthly bid amount (NAMBA) is projected to increase by $115, nearly 180%, to $179.45 in 2025.

At the end of September, California Gov. Gavin Newsom (D) vetoed a bill that would have subjected PBMs to a variety of new requirements and restrictions, saying he wasn’t convinced that it would achieve its goal of making prescription drugs more affordable.  

But what was a major defeat for supporters of SB 966 was a “huge win” for the ERISA Industry Committee (ERIC), which lobbied against California’s PBM-regulating bill even though it also vocally backs PBM reform on the federal level. In fact, ERIC and other like-minded groups representing large employers have long been siding with big PBMs’ main trade group in a pair of legal battles against PBM-targeting laws in Arkansas and Oklahoma. 

Founded in the 1930s by a Washington, D.C.-based hospital association, CareFirst BlueCross BlueShield is now one of the largest insurers in the Washington metropolitan area, leading the Maryland market and earning the No. 2 spot in the District. It largely offers commercial health products, including plans sold on the Affordable Care Act exchanges in D.C., Maryland and Virginia, as well as Medicare Advantage and Medicaid plans in Maryland. The insurer is relatively new to the public sector — it began offering MA products for the first time in 2021 and entered the Medicaid space via its 2020 acquisitions of Trusted Health Plan and the University of Maryland Medical System's Health Partners. CareFirst later lost its D.C. Medicaid contract in 2022, following a hotly contested bidding process. CareFirst is also the second-largest participant in the Federal Employee Health Benefits Program, behind Elevance Health, with about 635,000 members.