Spotlight on Market Access

It’s hard to underestimate the reach of artificial intelligence (AI) across the health care and pharmaceutical industries. While the ultimate impact of the technology on payers and providers may be debatable, pharma companies have made broader inroads into exploring ways to enhance their efforts, including in drug discovery. Still, caution in some areas is warranted, according to some studies.

For the Managed Care Biologics & Injectables Index: Q3 2023, from Aug. 13, 2023, to Sept. 29, 2023, Zitter Insights polled 35 commercial payers covering 117.7 million lives, 103 physicians and 83 practice managers about their familiarity with Open AI’s ChatGPT and AI tools in general.

With the launch of a new website, Eli Lilly and Co. recently became the first pharmaceutical company to offer weight loss medications though a telehealth provider. The platform — LillyDirect — comes less than two months after Lilly’s weight loss drug Zepbound (tirzepatide) gained FDA approval and joined fellow glucagon-like peptide 1 (GLP-1) agonists from Novo Nordisk A/S, Wegovy (semaglutide) and Saxenda (liraglutide), in the burgeoning obesity drug market.

The weight loss medication market is currently dominated by Wegovy, a once-weekly injectable drug. The FDA initially approved semaglutide for Type 2 diabetes under the brand name Ozempic, but the agency expanded the indications to include weight management three years ago. Pharmacy formularies that cover more than half of commercial-plan enrollees categorize Wegovy as “preferred” or “preferred with utilization management restrictions,” — such as prior authorization and/or step therapy — according to MMIT Analytics. (MMIT is the parent company of AIS Health.)

While pharma manufacturers for the most part are still adhering to their traditional business model, other entities in the drug channel are reorganizing, which will prompt drugmakers to be nimble as they adjust to the new reality. That’s one of the overarching themes moving into 2024 discussed during a recent webinar hosted by Adam J. Fein, Ph.D., CEO of Drug Channels Institute, which was recently acquired by HMP Global. In this second of a two-part series, AIS Health highlights the remaining industry trends projected by the longtime industry expert.

CVS Health Corp.’s PBM, CVS Caremark, said recently that it will remove AbbVie’s immunosuppressive drug Humira (adalimumab) from its major national commercial template formularies. The move comes on the heels of a year in which 14 near-identical copies of the world’s best-selling drug entered the U.S. market after years of delays, leading major PBMs to generally put selections of several biosimilars on the same coverage tiers as their reference product.

Yet while Wall Street analysts heralded CVS’s decision as an indication that it’s become a trailblazer in the biosimilar space, one prominent PBM critic remains skeptical of the company’s motivations — especially since CVS is working with Humira’s manufacturer on a new cobranded version of the drug.

As of the third quarter of 2023, enrollment in both employer-based plans and Medicare Advantage plans had risen compared to the same period in 2022, according to AIS’s Directory of Health Plans. Managed Medicaid membership dropped year over year by approximately 2.1 million lives and plummeted by nearly 5 million lives from the fourth quarter of 2022, as states starting in April resumed their Medicaid eligibility redeterminations processes. Meanwhile, the Affordable Care Act marketplace scooped up many disenrolled Medicaid beneficiaries, adding more than 3.1 million new members year over year.