Drug Coupons

After the introduction of newly FDA-approved, competing products in their therapeutic classes, the net price growth rate of select medications declined, according to an analysis published in the August issue of Health Affairs. The findings suggest that both “me too” therapies and PBM rebate negotiation might have an important role to play in reducing costs, researchers say.

The study found there was an estimated $10.4 billion reduction in net commercial spending for the existing therapies in the first three years after the introduction of the new medications. The authors noted that represented an 18.5% decline in projected spending on the existing therapies compared with if the new medications had never hit the market.

UnitedHealth Group has promoted Patrick Conway, M.D., to CEO of Optum Rx, the company’s PBM. Conway revealed the new role in a LinkedIn post. He was previously the CEO of Care Solutions at Optum, UnitedHealth’s health care services division. Heather Cianfrocco, Optum Rx’s CEO, is now the president of Optum. Before coming to UnitedHealth, Conway served as CEO of Blue Cross Blue Shield of North Carolina and as director of the Center for Medicare and Medicaid Innovation.

Mark Cuban Cost Plus Drug Co. has formed a partnership with Scripta Insights, a health care software company that works with health plans and self-insured employers to lower pharmacy benefit costs. Scripta plans on integrating the Mark Cuban company’s discounted pricing into its Med Mapper product. Alex Oshmyansky, CEO of Mark Cuban Cost Plus, said the companies “share a common goal of providing consumers the lowest possible price for their prescription medications.” The Mark Cuban company primarily sells generic medications at a discount, but earlier this year it began offering brand-name drugs from Janssen, a division of Johnson & Johnson Co., and IBSA Institut Biochimique SA, a pharmaceutical company based in Switzerland.

CVS Health Co.’s Caremark PBM struck a deal with GoodRx, Inc. that will allow eligible Caremark members to automatically access to GoodRx's prescription pricing at the pharmacy counter, which may lower their out-of-pocket costs for generic medications, per a July 12 press release. Using GoodRx coupons won’t affect members’ deductible and out-of-pocket threshold calculations, CVS added, noting that “plan members only need to utilize their existing benefit card at their preferred in-network pharmacy” to access the new discounts. “Through this program, patients don't have to choose between using their pharmacy benefit or using GoodRx to save on their prescriptions — now they can do both right at the counter so they have confidence they are always paying the lowest available price, said Scott Wagner, interim CEO of GoodRx. “This collaboration can make a meaningful difference for the tens of millions of Americans that CVS Caremark serves." The pact isn’t GoodRx’s first deal with a “big three” PBM — GoodRx also has a similar discount arrangement with The Cigna Group’s Express Scripts.

People with higher copays are significantly less likely to adhere to their commonly prescribed cardiovascular medications than those with low copays, according to a study published this month in JAMA Network Open. Utibe R. Essien, M.D., the study’s lead author, tells AIS Health the variations in adherence based on copays are “striking” and could have broader implications if some of the drugs are approved for obesity as expected and become even more widely used.

Utibe adds that people who do not take these drugs could have serious medical complications, leading to more of a health burden for them and financial burden for payers due to the high costs associated with hospitalizations, emergency room visits and other expenses.

In 2023, the country’s three largest PBMs are each excluding around 600 drugs from their standard formularies, according to a recent analysis from the Drug Channels Institute. That’s a greater number than ever before, as drug exclusion lists have risen every year for roughly the last decade. To one industry observer, that trend demonstrates the sticking power of the reigning PBM business model.

“The exclusion lists really reflect just the ongoing interest that PBMs have in increasing their bargaining power to leverage rebates,” says Ryan Urgo, a managing director at Avalere Health. It shows, ultimately, that “the rebate model remains alive and well,” he adds, referring to PBMs’ ability to negotiate deep discounts on branded drugs in exchange for favorable formulary placement, even if those drugs may have a higher list price.

UnitedHealth Group’s Optum Rx PBM is rolling out a new price shopping tool, while Amazon.com Inc.’s pharmacy division is offering a flat-rate monthly prescription service to Prime members. Experts tell AIS Health, a division of MMIT, that the new offerings are signs that disruptors like Amazon, Mark Cuban Cost Plus Drug Co. and GoodRx Inc. are mounting an effective challenge to traditional generics coverage inside the pharmacy benefit.

Amazon’s new offering, RxPass, will allow members to pay a flat fee of $5 per month to fill any combination of 52 eligible generics, plus free delivery, per a Jan. 24 press release. RxPass will be available in 42 states.

The copay accumulator bans passed in 15 states affect about 15 million people, or 11% of U.S. commercial plan members, according to research by consulting firm Avalere Health. Experts say the drug manufacturer-backed bans pick winners between payers and patients, but don't come close to solving the persistent problem of sky-high prices for life-saving drugs.

Copay accumulators are the practice, implemented by PBMs, of preventing the value of copay assistance programs from counting toward a plan member's deductible and out-of-pocket maximum calculation. A related practice, copay maximizers, spreads out the value of a copay coupon over 12 months while also preventing that coupon from counting toward a patient’s deductible/out-of-pocket maximum. Fifteen states and Puerto Rico have banned these practices in fully funded plans, which states can regulate — self-insured plans, since they are regulated by the Employee Retirement Income Security Act, are not included.

The FDA on Sept. 29 approved Relyvrio (sodium phenylbutyrate/taurusodiol), making it only the third medication to treat patients with amyotrophic lateral sclerosis (ALS). While ALS advocates and some clinicians applauded the agency’s decision, other providers have questioned the drug’s effectiveness, and some experts believe the drug is not cost-effective with its approximately $158,000 annual wholesale acquisition cost (WAC).

For instance, the nonprofit Institute for Clinical and Economic Review (ICER) found that Relyvrio, which was formerly known as AMX0035, would be cost-effective if it was priced at between $9,100 and $30,600 per year. And Bruce Booth, a former scientist who’s now a partner at the Atlas Venture biotechnology venture capital firm, wrote on Twitter that the $158,000 price for Relyvrio was “even more egregious than I thought!”

Spending in the U.S. on medicines increased by 12% in 2021, primarily because of COVID-19 vaccines and therapies, according to the IQVIA Institute’s annual report on drug trends. The report also found that “Despite an increase in overall spending, costs per prescription on average are flat or slightly declining. Prescription drug use reached a record 194Bn daily doses in 2021 as new prescription starts for both chronic and acute care recovered from the slowdown recorded in 2020…[but] spending on medicines is expected to return to pre-pandemic growth trend lines by 2023.”

A federal appeals court on July 25 held that a Pfizer Inc. coupon program violated the federal Anti-Kickback Statute. The Second Circuit Court of Appeals ruled that Pfizer offering copay assistance to Medicare beneficiaries was illegal under the statue. AHIP applauded the ruling, arguing that “By upholding these protections, the courts have taken an important step to protect Americans from what would otherwise be an unchecked multi-billion-dollar price tag that would make coverage and care less affordable for everyone.”

Pharmacy benefit consultants have mixed views on how many plan sponsors are turning to alternate funding programs, which aim to save on specialty drug costs by eliminating coverage for certain drugs and diverting costs to pharmaceutical companies’ patient assistance programs. But scrutiny of the programs is growing, with one major pharma company challenging the legality of these programs in court.

“A large percentage” of WTW’s employer clients now are using this strategy, Chantell Sell Reagan, Pharm.D., the national pharmacy practice clinical lead for WTW, tells AIS Health, a division of MMIT.