Benefit Design

Mileage of FTC Suit Against PBMs May Vary, Experts Suggest

When the Federal Trade Commission (FTC) officially accused the three largest PBMs of artificially inflating insulin prices, it marked the latest move in what has become a protracted effort by federal regulators to rein in the industry’s business practices.

However, experts who spoke to AIS Health say it’s unclear how much of an impact the FTC-driven litigation will have on the market — or whether the complaint itself will survive once the White House gains a new occupant.

Even if the FTC’s lawsuit is “robustly successful,” says Joe Shields, managing director of Transparency-Rx, it is focused on only one drug category. “That’s not meant as a criticism, but the reality is, what that means to the broader aspects of formulary or pharmacy benefit management, it’s an open-ended question,” adds Shields, whose organization of smaller PBMs is pushing for industry reform.

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Comments on FDA Interchangeability Draft Guidance Run the Gamut

Over the last few years, the FDA has taken multiple steps to level the playing field between biosimilars and interchangeable biosimilars. More recently, it proposed draft guidance that would do away with switching studies for interchangeability status. Commenters on that guidance were mostly supportive — with some even backing interchangeability for all biosimilars — and others asked for clarification on a range of issues, including what information the FDA needed to make a determination of interchangeability. Meanwhile, one group derided the guidance as an “ill-advised and inappropriate move.”

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Twice-Yearly PrEP Shows Promise in Clinical Trials

When the FDA approved the first injectable treatment for HIV pre-exposure prophylaxis (PrEP), the agency hailed the therapy as “an important tool in the effort to end the HIV epidemic” due to its every-two-months regimen, lessening the burden of oral treatments that were taken every day. But a new injectable agent may soon be approved that reduces that treatment burden to twice a year.

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As Biden Admin Winds Down, Will It Address Accumulators, Maximizers as Promised?

As President Joe Biden’s administration nears its end, two promised rules on copayment accumulators and maximizers have yet to be released. They stand to have a huge impact on whether pharma manufacturer-provided patient assistance — much of which is provided for specialty drugs — must be counted toward patients’ out-of-pocket responsibility.

The first concerns a lawsuit over the 2021 Notice of Benefit and Payment Parameters (NBPP) and its stance toward copay accumulators.

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Alignment Survey Reveals Barriers to Aging Well, Benefit Design Opportunities

Aging in place, lack of transportation and economic insecurity are the top social threats to seniors’ health, according to new data from Alignment Health. Sponsored by the tech-enabled Medicare Advantage insurer, the third-annual Social Threats to Aging Well in America survey polled more than 2,000 seniors across the U.S., asking them about their financial, physical and emotional needs — and how those needs are impacting their health. Their responses also highlight the types of supplemental benefits that could prove most valuable to seniors as they consider their coverage options while the 2025 Annual Election Period looms.

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Hospital Payment Caps: ‘Band Aid’ or Promising Cost-Control Solution?

Since Oregon placed a payment cap on hospitals for its state employee health plans, beneficiaries have seen a reduction in out-of-pocket spending and an increase in utilization, according to a recent JAMA Health Forum study. Roslyn Murray, Ph.D., the lead author, tells AIS Health that “there’s an appetite” from other states to implement similar price regulations, although they have faced pushback from providers.

The Oregon State Legislature passed a law in 2017 limiting in-network facility prices at 24 urban hospitals to 200% of Medicare prices and out-of-network hospital facility prices to 185% of Medicare prices. The legislation applied to members of the state employee plans, which provide benefits for two groups: educators in school districts and community colleges (known as the Oregon Educators Benefit Board) and employees of state agencies and universities (known as Public Employees Benefit Board).

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HCSC Sees ‘Steady Interest’ in Alternative Employer Plan Design

Health Care Service Corp. (HCSC), which owns Blue Cross Blue Shield plans in Illinois, Montana, New Mexico, Oklahoma and Texas, recently rolled out an “alternative health plan” that combines what essentially is a tiered provider network, price transparency and streamlined medical billing.

Industry experts who spoke to AIS Health, a division of MMIT, say HCSC’s new benefit design has a variety of intriguing elements that could prove attractive to employers. Indeed, UnitedHealthcare has in recent earnings calls been touting the rising popularity of a similar offering.

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Evernorth Reveals Stelara Biosimilar Strategy, but Will Others Get Same Discount?

Ahead of the much-anticipated launch of the next wave of biosimilars for a high-cost specialty drug, The Cigna Group’s Evernorth Health Services has said that it will roll out a program to manage the drugs that is similar to one it first began offering this summer. But several aspects of the upcoming launch remain unclear, including whether the discount provided for the new drug will be available to all payers.

Evernorth revealed on Sept. 5 that it will offer an interchangeable biosimilar of Stelara (ustekinumab) from Johnson & Johnson Innovative Medicine for $0 for “eligible patients” of Accredo starting “early next year.” The agent will be produced by Quallent Pharmaceuticals, Cigna’s private-label subsidiary.

The new agent’s price will be more than 80% less than Stelara’s list price. “For many employers, unions, municipalities and other health plan sponsors that choose to work with Accredo as part of their specialty pharmacy network offering, this represents an opportunity for significant savings,” said Evernorth in a press release.

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Quantile Health Wants to Help Self-Insured Plans Access CGTs

Most industry experts would agree that paying for costly cell and gene therapies (CGTs) is one of the top issues facing payers. And with more than 4,000 gene, cell and RNA therapies in the pipeline, the issue isn’t disappearing any time soon. One relatively new company is taking a slightly different approach to tackling the issue.

Quantile Health is focused on increasing patient access to CGTs, explained Yutong Sun, co-founder and CEO, during AHIP’s 2024 Medicare, Medicaid, Duals & Commercial Markets Forum, held earlier this year in Baltimore. As almost one-third of self-insured plans have dropped their coverage of gene therapies, the company is focused on this sector of the health care marketplace, which faces “quite different challenges” than other entities, she said. While CGTs may be “a drop in the bucket” for major national plans with annual budgets of a few billion dollars, one CGT could represent half of the annual budget for a self-insured plan with 100 to 500 employees.

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As Biden Admin Winds Down, Will It Address Accumulators, Maximizers as Promised?

As President Joe Biden’s administration nears its end, two promised rules on copayment accumulators and maximizers have yet to be released. They stand to have a huge impact on whether pharma manufacturer-provided patient assistance — much of which is provided for specialty drugs — must be counted toward patients’ out-of-pocket responsibility.

The first concerns a lawsuit over the 2021 Notice of Benefit and Payment Parameters (NBPP) and its stance toward copay accumulators.

Health plans and PBMs several years ago began implementing accumulators to counter manufacturer copay assistance programs. Traditionally, that assistance would count toward beneficiaries’ annual out-of-pocket expenses. When those out-of-pocket maximums were reached, health plans would cover the remainder of members’ costs for the year. With accumulators, patients can still use that assistance, but it does not help reduce their out-of-pocket costs.

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