RADAR on Drug Benefits

Major PBMs Look Ahead to 2023 for Biosimilars Boom

With a raft of biosimilars coming to market starting in 2023, major PBMs are touting the pharmacy infrastructure and services that they say will position them to help customers take advantage of cost-saving opportunities in the coming years.

Speaking during recent conference calls to discuss first-quarter 2022 financial results, they also reported healthy client retention levels as PBMs move through the large-employer selling season.

“Our team is quite excited about and well positioned for the accelerating biosimilar trend that we see in front of us for the coming years,” Cigna CEO David Cordani said during a May 6 conference call to discuss first-quarter 2022 financial results, per a transcript from The Motley Fool.

Centene Plans to Sell Magellan Rx, PANTHERx Rare for $2.8 Billion

Centene Corp. has agreed to sell two of its pharmacy businesses, Magellan Rx and PANTHERx Rare, in separate transactions as part of the insurer’s decision last year to exit the PBM industry.

Prime Therapeutics, a PBM jointly owned by 19 Blue Cross and Blue Shield affiliates, is acquiring Magellan Rx for about $1.35 billion in a deal that’s expected to close in the fourth quarter, while a joint venture of the Vistria Group, General Atlantic and Nautic Partners is buying PANTHERx Rare for $1.45 billion in a deal that’s expected to be completed in the next two to four months.

Study: With High Prices, Rebate Revenue Is Growing for PBMs

New research published in JAMA Health Forum found that rebate revenue for PBMs grew between 2015 and 2019 — but that growing rebate revenue was not passed on to patients.

The research letter’s authors measured both prerebate and postrebate drug costs taken from medical loss ratio (MLR) filings made by plans to CMS. The research sample includes commercial insurance filings from small group, individual and large group health plans across “approximately 2,200 unique health plans” covering 70 million lives.

Most Payers Will Review Humira Biosimilars as They Come

Starting next year, biosimilars are expected to generate significant pharmacy cost savings for patients and payers, led by multiple biosimilars of AbbVie Inc.’s blockbuster immunosuppressive drug Humira (adalimumab). With as many as eight Humira competitors expected to launch in 2023, most payers report they will evaluate the biosimilars as they come to market over the course of the year, rather than waiting until all are available before making coverage decisions. And half of payers may adjust Humira contracting in 2022, prior to the biosimilars’ launches.

That’s according to findings from Zitter Insights, which like AIS Health is a division of MMIT. Steve Callahan, a senior manager of market research at MMIT, described Zitter’s market research findings on the Humira biosimilars during an April 5 webinar.

Demand for Medication Abortion May Rise if Roe Falls

The use of medication abortion — which involves two drugs, mifepristone and misoprostol — has grown significantly since its approval and now accounts for 54% of all pregnancy terminations before nine weeks of gestation in the U.S. If the Supreme Court overturns Roe v. Wade, medication abortion usage is likely to increase as patients in states that ban the procedure are likely to attempt to obtain courses of medication abortion from states that allow it. Only 18 states and the District of Columbia allow both advanced practice clinicians and medical doctors to dispense abortion pills. Six states have passed laws banning any use of telehealth for medication abortion, according to a recent Kaiser Family Foundation analysis. Insurance coverage for both surgical and medical abortion is heavily regulated across the nation. A 2019 study from the Government Accountability Office found that 14 states’ Medicaid programs do not cover mifepristone even in the cases of rape, incest and life endangerment.

News Briefs: UnitedHealthcare to Restrict Aduhelm Access

UnitedHealthcare will restrict access to Aduhelm (aducanumab) across all of its books of business, arguing that “Aduhelm is unproven and not medically necessary for the treatment of Alzheimer’s disease due to insufficient evidence of efficacy,” according to company documents obtained by Stat News. The decision from the insurance branch of UnitedHealth Group, the largest private carrier in the country, follows a controversial move by CMS to restrict access to the drug mainly to patients who are participating in clinical trials. In a National Coverage Determination, CMS said the Medicare program will cover Biogen Inc.’s Aduhelm only for patients enrolled in randomized, controlled clinical trials conducted either through the FDA or the National Institutes of Health. For Medicare patients to be prescribed Aduhelm, they also must have a clinical diagnosis of mild cognitive impairment due to Alzheimer’s disease or mild dementia with a confirmed presence of plaque on the brain.

PBM Critics Increasingly Take Their Grievances to Court

As scrutiny on PBMs continues, various stakeholders are turning to the legal system to challenge the business practices of major firms.

Centene Corp. has been the target of the most litigation, having now reached settlements with nine state attorneys general over allegations that its PBM subsidiary Envolve overcharged those states’ Medicaid programs for prescription drugs, according to a filing with the Securities and Exchange Commission. The company has set aside $1.25 billion to fund those settlements and potential future lawsuits, and it is in the process of restructuring its PBM holdings.

Specialty Pharma Payer Deals Point to Outsourcing Trend

As prices for specialty pharmacy products continue to soar, payers are looking for new ways to gain more control over the distribution of expensive, often-provider-administered drugs. Last week, Kaiser Permanente and Highmark Blue Cross Blue Shield both struck deals aimed at managing specialty pharmacy spend — and one expert says that more deals like them are coming, especially from Kaiser’s new business partner, Cigna Corp. subsidiary Evernorth.

Kaiser Permanante (KP), the multistate integrated payer-provider based in California, doesn’t enter agreements with service providers outside its self-contained system very often. That said, Kaiser Permanente spokesperson Stephen Shivinsky tells AIS Health that “Kaiser Permanente and Accredo” — the specialty pharmacy division of Evernorth — “have had an existing relationship, which will expand further under part of this new agreement.”

A Look at Third-Party Oncology Clinical Pathways

In order to improve patient outcomes and reduce variations in oncology care, more and more payers and providers are adopting oncology clinical pathways (OCPs) — treatment protocols that aim to provide the optimal cancer care to patients at the lowest cost, according to a recent MMIT webinar. The share of oncologists exposed to third-party oncology pathways increased from 20% in 2015 to 52% in 2021, with one third of oncologists choosing a provider-focused pathway as of the fourth quarter of 2021. Breast cancer, multiple myeloma and non-small cell lung cancer are among the top therapeutic areas managed by third-party pathways.

Drug Price Controls Appear Central to Democratic Priorities

Democratic lawmakers are expected to make a strong push to revive a variety of drug pricing proposals, such as those that would grant CMS the ability to negotiate the price of certain drugs and place a cap on Medicare beneficiaries’ out-of-pocket spending.

House Majority Leader Chuck Schumer (D-N.Y.) has indicated he is targeting the current congressional work period that runs through Memorial Day as the time to make good on drug pricing plans that Democrats have long favored, noted Matt Kazan, managing director of policy with consultancy Avalere Health, during an April 27 webinar.

The convergence of several factors, including looming mid-term elections and the scheduled end of the COVID-19 public health emergency (PHE) could spur Democrats to make a last-ditch effort to resuscitate the Build Back Better Act (BBBA) and the drug pricing controls contained within it — especially since the end of the PHE could significantly impact Medicaid and Affordable Care Act (ACA) exchange enrollment.