Drug Rebates

PBMs Will Face Pressure From Transparency Rules, Startups

This year, PBMs will continue to face growing pressure from plan sponsors, regulators and policymakers to prove that they deliver value and keep drug costs down — and could face additional legislative or regulatory challenges to the way they do business. Meanwhile, investors are likely to put even more capital into startups that challenge the traditional pharmacy benefit paradigm, and the post-pandemic boom in risk-based contracting could expand into pharmacy benefits.

Federal and state regulators have increased scrutiny on PBMs in recent years. In particular, state efforts to regulate PBMs were buoyed by the Supreme Court’s 2020 decision in Rutledge v. Pharmaceutical Care Management Association (PCMA), a lawsuit in which the justices held that states were not in violation of the Employee Retirement Income Security Act of 1974 (ERISA) in attempting to regulate the rates at which PBMs reimburse pharmacies. According to the National Academy for State Health Policy (NASHP), a think tank and policy advocacy group, so far this year 42 states considered 111 bills relating to PBM regulation in 2021. That activity is likely to continue in 2022.

Report Trains Critical Eye on PBMs’ Changing Profit Streams

A new report about PBMs’ “evolving business models and revenue” is making a stir, with the main PBM trade group arguing that the organization behind it is biased and its conclusions are misguided. But industry observers tell AIS Health that the analysis offers illuminating information about how vertical integration and other factors have shaped the PBM sector — and they warn that PBMs must truly change if they are to survive increasing scrutiny.

Express Scripts Will Combine Coupons With Pharmacy Benefit

Express Scripts, the PBM subsidiary of Cigna Corp., will allow members to combine prescription drug coupons with their traditional pharmacy benefits. Pharmacy insiders tell AIS Health that the new offering is likely meant to head off competition from GoodRx Inc. and other upstarts.

A November blog post on the website of Evernorth, the Cigna subsidiary that owns Express Scripts, explains that around 2% of the time, discount pricing “is a little better” than the price offered when customers use their insurance.

News Briefs: Cigna settles $27.6 million PBM lawsuit with Kansas | Dec. 9, 2021

Centene Corp. will pay the state of Kansas $27.6 million, the fifth such settlement reached between the insurer and state Medicaid programs. More than a dozen states have sued the health insurer, accusing Centene of mismanaging their Medicaid programs’ pharmacy benefits. The insurer has paid out $214 million in settlements with Arkansas, Illinois, Mississippi and Ohio out of the $1.25 billion it set aside earlier this year to settle such suits. According to a press release from the office of Republican Kansas Attorney General Derek Schmidt, “In the settlement, Centene guarantees that it will improve transparency by providing the state with access to all data necessary to track pharmaceutical transactions, from the point of sale through reimbursement.” Centene is in the process of consolidating its $30 billion in pharmacy spend and hopes to bid out that business to one vendor in 2022.