Drug Rebates

Mark Cuban Cost Plus Drugs Strikes First Deals with Insurer, Outside PBM

Mark Cuban Cost Plus Pharmacy, the online pharmacy and generic manufacturing startup backed by the eponymous billionaire investor, recently struck its first deals with a health plan, Pennsylvania’s Capital Blue Cross, and a PBM, Rightway Healthcare Inc. The direct contracting deal represents a major step for the startup, which has done most of its business so far as a direct-to-consumer retailer — and one drug pricing expert tells AIS Health, a division of MMIT, that the deals help Cost Plus moves toward its ambitious, disruptive goals.

Mark Cuban Cost Plus Drugs Strikes First Deals with Insurer, Outside PBM

Mark Cuban Cost Plus Pharmacy, the online pharmacy and generic manufacturing startup backed by the eponymous billionaire investor, recently struck its first deals with a health plan, Pennsylvania’s Capital Blue Cross, and a PBM, Rightway Healthcare Inc. The direct contracting deal represents a major step for the startup, which has done most of its business so far as a direct-to-consumer retailer — and one drug pricing expert tells AIS Health, a division of MMIT, that the deals help Cost Plus moves toward its ambitious, disruptive goals.

Part D Bid and Base Premium Will Drop in 2023; MA-PD Enrollment Surpasses PDP for the First Time in 2022

The monthly Medicare Part D base beneficiary premium for 2023 will be $32.74, a slight decrease from $33.37 in 2022, according to CMS. The Part D national average monthly bid amount continues to drop, from $38.18 in 2022 to $34.71 in 2023. Regional low-income premium subsidy amounts have increased over the past few years in most states, yet five states — New York, Illinois, New Jersey, Indiana and Kentucky — are projected to see a decline larger than 5% in 2023. South Carolina is projected to see the biggest jump, with its average subsidy amount going up from $31.12 in 2022 to $37.84.

Part D Bid and Base Premium Will Drop in 2023; MA-PD Enrollment Surpasses PDP for the First Time in 2022

The monthly Medicare Part D base beneficiary premium for 2023 will be $32.74, a slight decrease from $33.37 in 2022, according to CMS. The Part D national average monthly bid amount continues to drop, from $38.18 in 2022 to $34.71 in 2023. Regional low-income premium subsidy amounts have increased over the past few years in most states, yet five states — New York, Illinois, New Jersey, Indiana and Kentucky — are projected to see a decline larger than 5% in 2023. South Carolina is projected to see the biggest jump, with its average subsidy amount going up from $31.12 in 2022 to $37.84.

National Average Part D Bid Continues Downward Trajectory, but for How Long?

In its annual release of the Medicare Part D payment benchmarks and other bid-related information for the coming plan year, CMS on July 29 reported that the national average monthly bid amount will continue a years-long downward trend, dropping to a historic low of $34.71. At the same time, monthly premiums are expected to take a slight dip. While both pieces of information — released by CMS in an effort to help Part D sponsors finalize their premiums and prepare for open enrollment this fall — reflect positive trends and a competitive market, upcoming changes included in the recently passed Inflation Reduction Act of 2022 could start to reverse those trends in the future.

The national average monthly bid amount is a weighted average of the standardized bid amounts for each stand-alone Prescription Drug Plan (PDP) and Medicare Advantage Prescription Drug (MA-PD) plan. Bids were submitted by PDPs and MA-PD plans in early June. CMS said it anticipates releasing the 2023 premium and cost-sharing information for 2023 Medicare Advantage and Part D plans in September.

Medicare Prescription Drug Price Negotiation Is Poised to Become Reality

It appears that for the first time, HHS will be able to negotiate prices of some prescription drugs in Medicare. The pharma industry has long resisted such efforts, and it remains to be seen what the impact of the legislation, if passed, will be on manufacturers’ drug discounts and rebates.
On Aug. 7, the Senate passed the Inflation Reduction Act of 2022 (IRA) 51-50 with Vice President Kamala Harris casting the deciding vote. The House is expected to vote on the bill Friday. If it passes as anticipated, President Joe Biden is projected to sign it into law shortly thereafter.

UnitedHealth Eyes No Out-of-Pocket Costs for Certain Drugs; Other Large Payers May Follow Suit

UnitedHealth Group announced on July 15 that it would eliminate out-of-pocket costs for insulin and a few other medications for beneficiaries enrolled in fully insured plans. The managed care organization expects to implement the changes starting as early as Jan. 1, 2023, pending regulatory approval.

Health and drug policy experts who spoke with AIS Health, a division of MMIT, applauded UnitedHealth’s decision, and noted it would benefit patients who struggle to pay for medications and increase adherence. They also said the move could help United financially, as members are more likely to stay out of the hospital and have better long-term health, but they said it could lead to higher premiums for employers and employees. UnitedHealth did not respond to AIS Health’s request for comment on how the company would foot the bill for implementing the zero cost-share policy.

Drug Price Reforms Return to the Senate’s Agenda

After more than a year of deliberation and false starts, Congress might finally reform pricing and federal purchasing of prescription drugs in the fall, D.C. insiders tell AIS Health, a division of MMIT. The substance of the drug pricing bill is similar to previous proposals, but the political ground inside the Democrats’ Senate caucus may have shifted enough to allow prescription drug pricing to eke through as part of a diminished catch-all spending bill that would still be the signature achievement of the beleaguered Biden administration.

Progress on the drug pricing bill resumed when Senate Majority Leader Chuck Schumer (D-N.Y.) on July 7 submitted the text of a bill to the Senate parliamentarian. The parliamentarian will deem whether the bill conforms with the Senate rules that govern the budget reconciliation process. Budget reconciliation is an arcane procedure that allows the Senate to pass legislation with a simple majority, so long as the bill in question relates largely, in the parliamentarian’s judgment, to the budget.

Payers Are Taking Steps to Manufacture Cheaper, More Accessible Generic Medications

The state of California announced last week that it would become the first state to manufacture its own insulin, while a payer-owned coalition said it would distribute its initial generic medication later this summer. Taken together, the moves show that some payers, be they the government or health insurers, are serious about reining in the costs of generics and dealing with inefficiencies in the pharmaceutical supply chain, according to health policy and drug pricing experts who spoke with AIS Health, a division of MMIT.

California Gov. Gavin Newsom (D) revealed the insulin plans on July 7 via a video on Twitter, keeping to a promise he had first made in 2019 when he was elected to office. The announcement followed the news in June that EmsanaRx became the first PBM to join CivicaScript, a company founded two years ago by a consortium of payers that is aiming to manufacture and lower the cost of generic medications in outpatient settings. In addition, Navitus Health Solutions, a startup PBM that touts a 100% pass through model, joined the CivicaScript partnership on July 13.

FTC Reveals PBM Investigation, Issues Policy Statement Targeting Rebates

As scrutiny over what Americans pay for prescription drugs continues, the Federal Trade Commission (FTC) is joining the action. In early June, the agency voted unanimously to launch an investigation of the business practices of the six largest PBMs. Then a little over a week later, it issued a statement on its enforcement policy on certain rebates and fees that manufacturers give PBMs that result in the exclusion of lower-cost drugs on their formularies. Industry experts say that PBMs should heed this “aggressive approach,” which appears to be challenging them to show that these rebates are justifiable and being passed on to patients and payers.

The focus comes after President Biden’s July 9, 2021, Executive Order on Promoting Competition in the American Economy in which he called for “a fair, open, and competitive marketplace” across numerous industries. “Americans are paying too much for prescription drugs and healthcare services — far more than the prices paid in other countries. Hospital consolidation has left many areas, particularly rural communities, with inadequate or more expensive healthcare options. And too often, patent and other laws have been misused to inhibit or delay — for years and even decades — competition from generic drugs and biosimilars, denying Americans access to lower-cost drugs.”