Radar on Drug Benefits

The state of California is facing delays in its efforts to produce low-cost insulin and is unlikely to meet its 2024 timeline, Bloomberg Law reports. Gov. Gavin Newsom (D) announced in March that the state had formed a partnership with Civica Rx to produce an insulin known as CalRx that would cost no more than $30 per 10ml vial and no more than $55 for a box of five, 3 mL pre-filled pens. However, California Health and Human Services Secretary Mark Ghaly, M.D., told Bloomberg Law the launch date would extend beyond 2024 due to unanticipated delays.

A group of 48 senators sent a letter to HHS Secretary Xavier Becerra, Dept. of Treasury Secretary Janet Yellen and Dept. of Labor Acting Secretary Julie A. Su asking for the Biden administration to require all insurers to fully cover over-the-counter (OTC) contraceptives. The politicians want the plans to cover the medications with no copays or out-of-pocket costs and without requiring a prescription. Opill, the first FDA-approved OTC birth control pill, is expected to become available early next year. The senators signing the bill included Patty Murray (D-Wash.), chair of the Senate Appropriations Committee; Bernie Sanders (I-Vt.), chair of the Senate Health, Education, Labor and Pensions Committee; and Ron Wyden (D-Ore.), chair of the Senate Finance Committee.

Major payer coverage policies across select categories often met fair access criteria for cost sharing, clinical eligibility, step therapy and provider restrictions, according to the third annual “Barriers to Fair Access” assessment published by the Institute for Clinical and Economic Review (ICER).

The analysis examined coverage policies for 18 drugs across 10 commercial formularies, eight Affordable Care Act exchange plans and the Veterans Health Administration national formulary, representing 42 million enrollees in total. ICER asked the payers for coverage policy information and leveraged the MMIT Analytics Market Access Database for additional information. (MMIT is the parent company of AIS Health, which maintains journalistic independence and did not play a role in producing the report.)

The specialty drug landscape continues to be a dynamic space, as new agents enter the market and existing ones gain FDA approval for additional indications. Global health care and specialty pharmacy solutions organization AscellaHealth recently released its quarterly breakdown of insights into treatments within the segment.

The Q3 2023 Specialty & Rare Pipeline Digest examines new approvals and launches of specialty drugs, including biosimilars, generics, and cell and gene therapies, as well as ones in the pipeline.

After Blue Cross Blue Shield of Michigan implemented a five-day opioid prescribing limit in 2018, members who underwent general surgeries were prescribed and filled fewer prescriptions and had similar patient-reported outcomes compared with enrollees who had procedures before the program was initiated, according to a study published in JAMA Health Forum on Oct. 13.

James Grant, M.D., BCBS of Michigan’s chief medical officer, tells AIS Health, a division of MMIT, that the results show payers can steer people away from potentially addictive opioids without having a negative impact on their pain management.

Rite Aid Corp.’s recent Chapter 11 bankruptcy filing could present an opportunity for health insurers and PBMs to poach some of the firm’s assets. Humana Inc. is one of the retail pharmacy chain’s largest creditors, and PBM MedImpact Healthcare Systems, Inc. has offered to buy Rite Aid’s PBM division for $575 million.

Experts tell AIS Health, a division of MMIT, that the bankruptcy is tangible proof that retail pharmacy firms are doomed if they don’t diversify. More than ever, consumers shop for both prescriptions and household items online, trends sped up by the COVID-19 pandemic.

Although PBMs are taking increasing heat for spread pricing — or charging payers more for a drug than pharmacies are reimbursed — they aren’t the only players in the drug supply chain that engage in the practice, a new study points out. And one of the study’s authors says its findings suggest that patients may be better off if generic drugs are simply removed from insurance coverage entirely.

The study, published in JAMA Health Forum on Oct. 20, examined data associated with 45 high-utilization Medicare Part D-covered generic drugs.

Only 2% of Medicare beneficiaries who enrolled in a stand-alone Prescription Drug Plan (PDP) in 2024 will be in contracts with 4 or more stars, compared to 42% in the 2022 plan year and 9% in 2023, according to CMS’s recently released estimates. The average Star Rating for PDPs dropped to 3.11 in 2024 from 3.70 in 2022, with two contracts receiving 1.5 stars.

The distribution change is largely fueled by methodology changes in how many of the Star Ratings are calculated. Known as Tukey outlier deletion, the changes center on removing outlier contract scores when determining the cut points for all non-Consumer Assessment of Healthcare Providers and Systems measures.

Almost two years after Paxlovid received emergency authorization as a treatment for acute COVID-19 infection, Pfizer Inc. and the U.S. government are now in the throes of transitioning the drug to the commercial market. That means the drugmaker is, in its own words, “working diligently with payers to achieve the best possible formulary placement” for Paxlovid — but also raising some eyebrows with the list price it set for the antiviral therapy.

Pfizer said in a statement that the commercial list price for Paxlovid (nirmatrelvir/ritonavir) in the U.S. will be $1,390 per five-day treatment course. That’s more than twice what the U.S. government paid for the drug, $529 per five-day course, and significantly higher than the price range of $563-$906 that the Institute for Clinical and Economic Review (ICER) suggested would be most cost effective.

Amazon.com Inc. will deliver prescriptions via drone in College Station, Texas, the e-commerce giant said on Oct. 18. The online retailer said it will fill and deliver prescriptions for Amazon Pharmacy customers via drone in “60 minutes or less,” and that more than 500 medications can be delivered using the service. An Amazon press release claims that “Amazon’s drones have safely delivered hundreds of household items in College Station since December 2022.” Intermountain Health, the Utah-based integrated health system, has delivered prescriptions by drone since 2021 in the Salt Lake City area, the Associated Press reports.

Elevance Health Inc.’s CarelonRx PBM will add two of Boehringer Ingelheim’s Humira (adalimumab) biosimilars to some of its formularies starting Dec. 1, the firm said on Oct. 19. The move will put those drugs “at parity with Humira,” per a press release. The lower-list-price version of adalimumab-adbm will be added to all CarelonRx’s commercial formularies, while Boehringer’s Cyltezo will be added to “select” commercial formularies, the press release added.

The state of Hawaii on Oct. 4 in federal court sued the Big Three PBMs — CVS Health Corp.’s Caremark, UnitedHealth Group’s Optum Rx, and The Cigna Group’s Express Scripts. The suit accuses the firms of “siphon[ing] increasing amounts of money from the pharmaceutical supply chain while significantly increasing prices for consumers, employers, and other health care payers” through unfair trade practices. According to a press release from Hawaii Gov. Josh Green, M.D., and Attorney General Anne Lopez, both Democrats, the complaint accuses PBMs of “unfair methods of competition and unfair and deceptive acts and practices in violation of Hawaiʻi law,” such as inappropriate fees charged to manufacturers for formulary placement. The state will seek civil penalties of $10,000 per violation, with additional penalties sought for “each deceptive or unfair act that was directed towards an elder.”