Spotlight on Market Access

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.

For nearly all services and functions, employers had higher levels of satisfaction than health plans in 2024. The ratings differ significantly in delivery of promised services, contract and service flexibility, and responsiveness and issue resolution.

Many respondents said their PBMs have strategies for new and upcoming biosimilars in 2024 and acknowledged the importance of having such strategies. Yet they expressed mixed feelings about their PBMs’ Humira biosimilar strategy, with 10% indicating they were dissatisfied and just 16% saying they were very satisfied.

The last of the so-called Big Three PBMs recently joined the others in offering a new private-label subsidiary when it unveiled upcoming changes to its commercial formularies. Those units, which are largely focused on biosimilars and generics, may offer benefits to pharma companies partnering with them, but such arrangements also pose potential risks as the offerings are already drawing scrutiny.

On Jan. 1, 2025, UnitedHealth Group’s Optum Rx will place Nuvaila-labeled biosimilars of Stelara (ustekinumab) from Johnson & Johnson Innovative Medicine and AbbVie Inc.’s Humira (adalimumab) on various tiers of three of its commercial formularies for a zero-dollar copay. In partnership with Amgen Inc. for its interchangeable Wezlana (ustekinumab-auub), Wezlana for Nuvaila will be available in both high-wholesale acquisition cost and low-WAC versions.