Drug Pricing

Facing Complaints, BCBS of North Carolina Shifts HIV Drugs to Lower Tiers

Two patient advocacy groups are declaring victory after Blue Cross Blue Shield of North Carolina made midyear formulary changes that shifted several HIV treatments from higher to lower tiers, meaning patients can access them at much lower cost-sharing levels.

In an Aug. 31 press release, the HIV+Hepatitis Policy Institute and the North Carolina AIDS Action Network pointed out that the move came after they filed discrimination complaints with the North Carolina Dept. of Insurance and HHS’s Office for Civil Rights arguing that the Blue Cross NC formulary violated the Affordable Care Act’s prohibitions against discriminatory plan design. The formulary in question is the Blue Cross and Blue Shield of North Carolina Essential Formulary, which applies to ACA marketplace plans sold in the state.

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Majority of Drugs Selected for Price Negotiation Are on ‘Preferred’ Tiers in Medicare

Major blood thinners are among the first 10 prescription drugs for which the Biden administration will seek lower Medicare prices as part of the Inflation Reduction Act (IRA). The negotiated prices will be announced on Sept. 1, 2024, and go into effect in 2026.

Medicare beneficiaries who filled prescriptions for the 10 selected drugs paid a total of $3.4 billion in out-of-pocket costs for those therapies in 2022. The Medicare program paid more than $50 billion for the drugs between June 2022 and May 2023, CMS reported. Bristol Myers Squibb’s blood thinner Eliquis (apixaban) alone accounted for more than $16 billion.

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Medicare Part D Sponsors Grapple With Unknowns as Drug Price Negotiations Begin

CMS on Aug. 29 unveiled the long-awaited list of 10 drugs for which Medicare will negotiate prices and included drugs to treat common diseases like diabetes, high blood pressure and certain cancers. Industry experts tell AIS Health, a division of MMIT, that while the list provides Part D stakeholders with some new clarity, a host of uncertainties remain, such as how the negotiation process itself will unfold and how plan sponsors will respond to mandated benefit design changes in 2025. But if CMS prevails in implementing drug price negotiation with no delays from manufacturer lawsuits, sources are hopeful that the new process will ultimately provide more insight and fewer uncertainties for subsequent rounds of negotiation.

Based on criteria outlined in the Inflation Reduction Act (IRA), CMS is tasked with selecting drugs for price negotiation, beginning with 10 Part D drugs in 2026, an additional 15 Part D drugs for 2027, and another 15 Part D and Part B drugs in 2028. Starting in 2029, the agency will add another 20 Part D and Part B medications each year to the list. The Congressional Budget Office (CBO) has projected that Medicare will save $3.7 billion in 2026, $8.3 billion in 2027 and $17.5 billion in 2028.

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© 2024 MMIT

Majority of Drugs Selected for Price Negotiation Are on ‘Preferred’ Tiers in Medicare

Major blood thinners are among the first 10 prescription drugs for which the Biden administration will seek lower Medicare prices as part of the Inflation Reduction Act (IRA). The negotiated prices will be announced on Sept. 1, 2024, and go into effect in 2026.

Medicare beneficiaries who filled prescriptions for the 10 selected drugs paid a total of $3.4 billion in out-of-pocket costs for those therapies in 2022. The Medicare program paid more than $50 billion for the drugs between June 2022 and May 2023, CMS reported. Bristol Myers Squibb’s blood thinner Eliquis (apixaban) alone accounted for more than $16 billion.

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© 2024 MMIT

Facing Complaints, BCBS of North Carolina Shifts HIV Drugs to Lower Tiers

Two patient advocacy groups are declaring victory after Blue Cross Blue Shield of North Carolina made midyear formulary changes that shifted several HIV treatments from higher to lower tiers, meaning patients can access them at much lower cost-sharing levels.

In an Aug. 31 press release, the HIV+Hepatitis Policy Institute and the North Carolina AIDS Action Network pointed out that the move came after they filed discrimination complaints with the North Carolina Dept. of Insurance and HHS’s Office for Civil Rights arguing that the Blue Cross NC formulary violated the Affordable Care Act’s prohibitions against discriminatory plan design. The formulary in question is the Blue Cross and Blue Shield of North Carolina Essential Formulary, which applies to ACA marketplace plans sold in the state.

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© 2024 MMIT

Medicare Drug Price Negotiation: ‘Spillover Effect’ on Private Market Remains Fuzzy

The Biden administration on Aug. 29 released its long-awaited list of the first 10 drugs that will be subject to price negotiation in the Medicare program, representing the first major step toward implementing the most ambitious drug-pricing reform in the Inflation Reduction Act (IRA).

While the new price-negotiation program will apply only to Medicare — not employer-based or individual market plans — industry experts say it will almost certainly affect the commercial insurance market indirectly. But they tell AIS Health, a division of MMIT, that exactly what the impact will look like hasn’t fully come into focus.

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CVS Launches New Biosimilar White Label, But Can it Bring Down Costs?

CVS Health Corp. plans to launch its own white-label line of biosimilars, the retail and health care giant said on Aug. 23, in a play to lower specialty pharma costs. Experts say that it could be years before anyone is able to tell whether the venture has brought down costs — especially since the biosimilar market itself is still in its early stages of development.

The new CVS brand, Cordavis, will be “a wholly owned subsidiary that will work directly with manufacturers to commercialize and/or co-produce biosimilar products,” a press release said. The division “will help ensure consistent long-term supply of affordable biosimilars,” and, in doing so, leverage “one of the biggest opportunities for reducing drug costs for employers and consumers.”

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Large Employers Worry Over Worsening Worker Mental Health, Drug Costs

When asked about the COVID-19 pandemic’s impact on their employees’ health and well-being, a whopping 77% of employers surveyed by the Business Group on Health said they are currently seeing increased mental health issues in their workforce. And based on other findings in the employer coalition’s annual survey, companies are counting on their health plan partners to help them address this growing issue.

According to Business Group on Health Vice President Brenna Shebel, “77% is a stark jump over last year,” when 44% of employers said they were seeing an uptick in conditions such as substance use disorders, depression and anxiety. This year, another 16% of employers said they anticipate seeing an increase in mental health issues in their workforces in the future, “so certainly a key finding here is the dire need for mental health services and supporting their employees as they’re navigating their myriad needs in the area of mental health,” Shebel added during an Aug. 22 virtual press event held to present Business Group on Health’s findings.

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News Briefs: CVS Launches Biosimilar-Focused Subsidiary

CVS Health Corp. on Aug. 23 launched a subsidiary called Cordavis, which will work with drug manufacturers to “commercialize and/or co-produce biosimilar products.” CVS said it has contracted with Sandoz to bring Hyrimoz, a Humira biosimiliar, to market in the first quarter of 2024 under a private Cordavis label. The list price of Cordavis Hyrimoz, the company said, will be “more than 80% lower than the current list price of Humira.” Sandoz launched a branded, high-concentration formulation of Hyrimoz on July 1, joining several other Humira biosimilars that launched in the same month.

On Aug. 21, Pfizer Inc.’s Abrysvo became the first vaccine approved by the FDA for use in pregnant people to prevent respiratory syncytial virus (RSV) in infants. The vaccine, which is administered in one dose, is approved for use at 32 through 36 weeks gestational age of pregnancy, and it can prevent lower respiratory tract disease caused by RSV in infants from birth through six months old. In May, the FDA approved Abrysvo for the prevention of lower respiratory tract disease cause by RSV in people age 60 and older. The FDA in July approved AstraZeneca and Sanofi’s Beyfortus (nirsevimab-alip) for preventing RSV in infants, and the Centers for Disease Control and Prevention in early August recommended the vaccine be given to all infants under 8 months and some older babies at increased risk of severe illness starting this fall.

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Blue Shield of California’s Carve-Out Deals Are ‘Warning Shot’ to Big Three PBMs

Blue Shield of California will shift from a traditional PBM contract with CVS Health Corp.’s Caremark to a pharmacy benefits model that uses five different vendors to fulfill the discrete functions that Caremark previously managed all at once, the nonprofit carrier said Aug. 15. Managed care and pharmacy insiders say the move is just the latest sign that employers and regional carriers are dissatisfied with the services large PBMs provide, and they suggest that more plans could follow Blue Shield’s example if the model is successful.

According to Blue Shield of California Chief Operating Officer Sandra Clarke, when the insurer’s Caremark contract lapses at the end of this plan year, the Blues affiliate will begin agreements with five different firms to manage its various pharmacy benefit operations:

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