PBMs/Pharmacy Benefit Managers

Coverage of First Humira Biosimilar Varies on ‘Big Three’ PBMs’ Formularies

Following the launch of Amgen Inc.’s Amjevita (adalimumab-atto), a slew of other FDA-approved Humira (adalimumab) biosimilars entered the U.S. market in July under settlement agreements with Humira originator AbbVie Inc. Major PBMs quickly announced that they would add more biosimilars to their formularies to compete with Humira.

At the end of June, UnitedHealth Group’s Optum Rx said it will place Boehringer Ingelheim's Cyltezo (adalimumab-adbm) and Sandoz's Hyrimoz (adalimumab-adaz) on its formulary at parity with Humira starting July 1. The Cigna Group’s Express Scripts then said it would add three biosimilars — Cyltezo, Hyrimoz and adalimumab-adaz (the unbranded equivalent of Hyrimoz) — to its list of preferred drugs.

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© 2024 MMIT

House Advances Site of Care Identification, Third-Party Fee Disclosure Bills

As part of a recently introduced health care package, the U.S. House of Representatives’ Committee on Education and the Workforce on July 12 unanimously advanced a bill that would require hospital groups to create individual identifiers for outpatient departments — a major step toward so-called “site neutrality,” a long-held goal of plan sponsors and carriers. The other bills, meanwhile, are mainly focused on PBMs, which have become the hottest health care topic — and for some members, the most notable health care villains — in the current session of Congress.

The overwhelming support from members of both parties for each of the bills bodes well for their eventual passage. So does their alignment with bills currently under consideration in the Senate, according to one D.C. insider.

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Coverage of First Humira Biosimilar Varies on ‘Big Three’ PBMs’ Formularies

Following the launch of Amgen Inc.’s Amjevita (adalimumab-atto), a slew of other FDA-approved Humira (adalimumab) biosimilars entered the U.S. market in July under settlement agreements with Humira originator AbbVie Inc. Major PBMs quickly announced that they would add more biosimilars to their formularies to compete with Humira.

At the end of June, UnitedHealth Group’s Optum Rx said it will place Boehringer Ingelheim's Cyltezo (adalimumab-adbm) and Sandoz's Hyrimoz (adalimumab-adaz) on its formulary at parity with Humira starting July 1. The Cigna Group’s Express Scripts then said it would add three biosimilars — Cyltezo, Hyrimoz and adalimumab-adaz (the unbranded equivalent of Hyrimoz) — to its list of preferred drugs.

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© 2024 MMIT

Fein: Patients Are Trapped in ‘Doom Loop of Specialty Drug Benefits’

Plan sponsors’ use of copayment accumulators, copay maximizers and alternative funding companies to keep spending on specialty drugs down has been a fairly recent trend but one that continues to pick up speed, noted longtime industry expert Adam J. Fein, Ph.D., CEO of Drug Channels Institute, during a recent webinar. But as that use continues to increase, multiple questions exist around the practices and what the future holds for them.

The focus of the June 23 webinar, titled PBMs and the Battle Over Patient Support Funds: Accumulators, Maximizers, and Alternative Funding, mainly affects specialty drugs, which now represent more than half of payer spending on drugs due to two main reasons, he said. The first is the specialty drug pipeline and the costly prices of those agents, while the second is the dramatic growth in generic dispensing over the past 20 years.

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News Briefs: CVS, GoodRx Cut Coupon Deal

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.

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PBMs Keep New Biosimilars on Equal Footing With Best-Selling Humira

Since the first biosimilar for Humira launched in the U.S. this January, it’s been joined by several other biosimilars referencing AbbVie Inc.’s blockbuster immunosuppressive drug — with each manufacturer trying to differentiate their offerings in a suddenly crowded market. Major PBMs Optum Rx and Express Scripts have both responded by adding some of the newly launched biosimilars to their standard commercial formularies, while CVS Caremark appears to be still considering its options.

Experts who spoke with AIS Health, a division of MMIT, shared a variety of viewpoints about how coverage of the newly launched biosimilars is shaping up. But all are closely watching how PBMs, physicians and patients respond to the influx of competition for AbbVie’s cash cow, which has earned the drugmaker $208 billion globally since it was first approved by the FDA in 2002.

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Payers Adopt Initiatives to Address ‘Pharmacoequity’

For the past couple of years, payers have been focusing more attention on health inequities related to race, income and other factors by hiring staff and investing money in programs to improve access to care and lower costs. More recently, they have adopted similar strategies to address inequities in the pharmacy side of their businesses, according to health plan executives who spoke at a conference last month at the University of Pittsburgh.

The push among payers is known as “pharmacoequity,” a term popularized by Utibe Essien, M.D., an internal medicine physician and assistant professor at UCLA. Essien, who moderated the panel with the payer executives, defines pharmacoequity as “equity in access to pharmacotherapies or ensuring that all patients, regardless of race and ethnicity, socioeconomic status, or availability of resources, have access to the highest quality of pharmacotherapy required to manage their health conditions.”

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New House, Senate Bills Add to Accumulating PBM Reform Proposals

Although several PBM reform measures are already circulating in Congress, lawmakers recently added even more legislative proposals to the fray. The Senate Finance Committee released a discussion draft that would introduce a host of financial reporting requirements for PBMs contracted by Medicare Part D plans, and then announced it would mark up a package including that measure and other PBM reforms later this month. And, following a markup, the House Education and Workforce Committee advanced a spate of bills focused on promoting transparency for PBMs, health care providers and insurers.

A Capitol Hill insider tells AIS Health, a division of MMIT, that how exactly these measures will fit into a final package of PBM reform legislation remains to be seen, although a few possible scenarios are beginning to come into view.

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Provider, PBM Assets Grow to Comprise More of Insurers’ Revenue

While strong premium revenue was one major reason for insurers’ favorable results in 2022, rising fee-based income from PBM and health care delivery assets has also played a major role in those firms’ rising fortunes. While that fact is largely viewed favorably by industry analysts, it’s also been increasingly criticized by lawmakers and other stakeholders concerned about vertical integration in the health care industry.

“From a ratings perspective, it’s good,” remarks Dean Ungar, a vice president and senior analyst at Moody’s Investors Service. “The diversified revenue stream is better than having a concentrated revenue stream. Of course, the caveat is, if you don’t execute well or if you make acquisitions that are not good acquisitions, you could end up with problems.”

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Accumulators, Maximizers, Alternative Funding Models Contribute to ‘Doom Loop of Specialty Drug Benefits’

As plan sponsors continue to grapple with the high costs of specialty drugs, they have undertaken various strategies to deal with them. The use of copayment accumulators, copay maximizers and alternative funding companies has been a fairly recent trend, noted longtime industry expert Adam J. Fein, Ph.D., CEO of Drug Channels Institute, during a recent webinar. But as that use continues to increase, multiple questions exist around the practices and what the future holds for them.

Fein explained that he chose the focus of the June 23 webinar, titled PBMs and the Battle Over Patient Support Funds: Accumulators, Maximizers, and Alternative Funding, because the entities are a hot industry topic currently. “And I think this is a topic of great relevance to manufacturers, to PBMs, to plan sponsors, to patients, to pharmacies, to everyone in the channel. And it’s one that I found is not well understood,” he stated.

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© 2024 MMIT