Benefit Design

2023 Drug Trends Included GLP-1s, Humira Biosimilars, $0 Cost Share

Notable pharmacy benefit trends in 2023 claims data included increased use of GLP-1s for weight loss, shifting market dynamics amid high demand for AbbVie Inc.'s Humira (adalimumab) and its biosimilar competitors and increasing approval of expensive gene therapies. All this took place amid “persistent price inflation” across most drug categories, according to a new report by PBM analytics firm Xevant.

According to Xevant’s 2023 Drug Trend Report, which analyzed pharmacy claims data from its commercial plan clients, 2023 plan-paid amounts across all brand and generic non-specialty and specialty drugs went up an average of 20% from 2022. In addition, the number of specialty prescriptions processed by plans increased by 11% in 2023. GLP-1 utilization increased by 400%, while claims for Humira and its biosimilars increased by 25%.

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Part D Plans Get Ready for Potentially ‘Messy’ Rollout of M3P Program

This article originally appeared as part of the May 16 issue of Radar on Medicare Advantage.

For the first time ever, Medicare Part D beneficiaries in 2025 will have the opportunity to spread their prescription drug expenses over the course of the plan year. While Part D sponsors must offer the option to enrollees effective Jan. 1, 2025, plans face multiple considerations and tasks prior to then. One of their most immediate concerns, industry experts say, is factoring in potential administrative costs and/or financial losses associated with the new Medicare Prescription Payment Plan (M3P, as many are calling it) into bids due next month.

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SCAN CEO Challenges Industry to Take Stock of Mission-Driven Work

In recent years, publicly traded managed care organizations have jumped on a growing corporate trend of publishing annual environmental, social and governance (ESG) reports designed to spotlight the larger impact their company is having on society. Alignment Healthcare Inc., for one, in 2022 released its inaugural ESG report highlighting efforts from the previous year that focused on delivering high-quality care at a lower cost compared to fee-for-service Medicare and addressing social determinants of health (SDOH). In 2023, The Cigna Group’s 98-page ESG report categorized similar efforts into four “pillars” — healthy society, healthy workforce, healthy company and healthy environment — and included efforts to reduce greenhouse gas emissions in the latter category.

In a 2022 podcast hosted by law firm K&L Gates LLP, speakers suggested that the health care industry by nature is “mission-driven…focused on the improvement of the human condition” and “is particularly well suited to address ESG issues.” And insurers’ efforts in recent years to address health inequities mirror the increased focus from the Biden administration and CMS on tying health equity to reimbursement, such as the CMS Innovation Center incorporating health equity into models that drive value-based care.

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HSA-Eligible Plans Have Mixed Impact on Health Care Use, No Impact on Spending

People with health savings account-eligible high-deductible health plans (HDHPs) use less outpatient services and fill fewer prescription medications than people with PPOs, but HSA plan enrollment appears to have no impact on total health care spending, according to a recent study published by the Employee Benefit Research Institute (EBRI).

As of 2022, 57.9% of employees were enrolled in an HSA-eligible health plan, while 32.3% of them were in an HDHP that was not associated with an HSA.

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Established TKI Gains New Indication to Treat Aggressive Cancer

After first gaining approval more than a decade ago, Takeda Pharmaceuticals U.S.A., Inc.’s Iclusig (ponatinib) recently gained approval for the frontline treatment of an aggressive blood cancer. One clinical trial found that people on the agent experienced complete remission more than twice as often as those on a comparator therapy. Industry sources point to the drug’s clinical efficacy as a significant development in the treatment of the disease.

On March 19, the FDA gave accelerated approval to Iclusig in combination with chemotherapy for the treatment of adults with newly diagnosed Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL). The newest application had priority review and orphan drug designation, and its review used the Real-Time Oncology Review and the Assessment Aid.

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AMCP Panel Details Barriers to Broad Biosimilar Adoption

For biosimilar use to truly take flight, health plans need to focus on easing switches between original products and reference products — and policymakers should consider expanding interchangeability, according to expert presenters at the Academy of Managed Care Pharmacy (AMCP) annual conference in New Orleans.

There is a lot of "promise" and "optimism" around biosimilars, said Cate Lockhart, Pharm.D., Ph.D., executive director of the Biologics and Biosimilars Collective Intelligence Consortium, during an April 17 panel at the AMCP conference, but there is more that could be done to increase systemic savings and improve patient access.

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Payers Continue to Employ Array of Specialty Drug Management Strategies

Rebates continue to be a huge part of the specialty pharmacy space, with 93% of respondents to a recent survey receiving them for drugs in the pharmacy benefit. Meanwhile, 44% of respondents said their firm received rebates for medical benefit drugs, representing an increase from 39% in the prior year’s survey. Those are just some of the findings in the Trends in Specialty Drug Benefits Report from Pharmaceutical Strategies Group (PSG), an EPIC company.

The 11th annual survey, which reflects 2023 information, was fielded from Sept. 18 through Oct. 13, 2023. The primary source of respondents was PSG’s proprietary database of drug benefit decision makers, and they included people from employers, health plans (or third-party administrators or insurance companies) or union/Taft-Hartley plans. There were 185 benefits leaders from plan sponsors with an estimated 86.6 million lives.

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PBM Moves Spur Humira Biosimilar Uptake but Raise Questions

The FDA has approved 10 biosimilars of AbbVie Inc.’s Humira (adalimumab), with nine of them launching in the U.S. since last year, but uptake of them has been relatively slow. Recently, though, a formulary change by CVS Health Corp. seems to have spurred uptake of the agents, and an upcoming change by The Cigna Group should increase their use again. However, some industry experts question whether those changes were made with an eye on increasing biosimilar access — or boosting their own profits.

On April 25, Evernorth Health Services, a subsidiary of Cigna, revealed that it will have a high- and low-concentration interchangeable Humira biosimilar for zero out-of-pocket costs for “eligible patients” of its specialty pharmacy, Accredo, starting in June. The product, according to a press release, “will be produced for Evernorth’s affiliate private label pharmaceutical distributor, Quallent Pharmaceuticals, through agreements with multiple manufacturers.”

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Implications of IRA, GLP-1s, CGTs Are Top of Mind for Payers

The pharmaceutical industry continues to bring innovative therapies to market, but payers are continuing to grapple with how they can manage their financial impact. And while the Inflation Reduction Act (IRA) may bring some relief to Medicare beneficiaries in the form of lower drug prices and out-of-pocket costs, uncertainties remain about how that legislation could impact commercial payers, according to speakers at AHIP’s 2024 Medicare, Medicaid, Duals & Commercial Markets Forum, held March 12 through 14 in Baltimore.

During a March 13 session, titled “Trends in Prescription Drug Affordability, Innovation and Access,” a large part of the panel discussion focused on the IRA, which put “a lot of pressure on all parts of our health care system, but pharma got the brunt of it,” observed Rena Conti, Ph.D., associate professor at Boston University’s Questrom School of Business. While much of the focus from pharma and politicians has been on the drug price negotiation process, the Medicare Part D redesign “is actually a really big thing, because that’s what’s going to lower prices for seniors,” she asserted. “And it also will put a fair amount of pressure back on plans to manage this benefit.”

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Rumored Regs Could Help Payers, PBMs Streamline Digital Therapeutic Coverage

Notable changes to the way breakthrough medical devices are covered by Medicare and other payers could be coming soon, with CMS poised to make some therapeutics eligible for Medicare coverage, and some stakeholders pushing for new legislation to expand digital therapeutic coverage. In the meantime, commercial health plans and PBMs are grappling with how best to cover prescription digital therapeutics (PDTs).

Health plans and PBMs have varying approaches to digital therapeutic reimbursement. Some plans may place one digital therapeutic in the medical benefit, while others may cover PDTs as part of a pharmacy benefit. That’s because PDTs occupy a unique space in the health benefits landscape: They aren’t pharmaceuticals, but they share many characteristics of a maintenance medication in practice.

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