PBMs/Pharmacy Benefit Managers

Senate HELP Panel PBM Bill Requires Rebate Pass-Through, but not to Plan Members

Pharmacy benefit manager reform legislation co-authored by Senate Health, Education, Labor and Pensions Committee chair Bernie Sanders (I-Vt.) and ranking member Bill Cassidy (R-La.) addresses the hot-button issue of rebates but not in the way biopharma manufacturers are hoping for.

It would require PBMs to remit “100% of rebates, fees, alternative discounts and other remunerations received…that are related to utilization of drugs under such health plan or health insurance coverage to the group health plan.” Biopharma companies have for years been pushing for a policy that mandates rebates be passed through, not with health plans as envisioned by the legislation, but with plan enrollees at the point-of-sale as a better way to “share the savings.”

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© 2024 MMIT

Express Scripts, Optum Rx Tout Transparency, Cost-Capping Initiatives

Express Scripts and Optum Rx recently disclosed initiatives including pass-through arrangements, lower copays and price matches that they say will help clients and members save money and increase transparency. Marc Guieb, Pharm.D., a consulting pharmacist with Milliman, Inc., says the announcements are not “new or revolutionary or anything” and that they “seem to be rebranding of existing programs and products that are already offered.”

Guieb notes that the press releases are likely in response to the increasing scrutiny the PBM industry faces from politicians and others. Several Senate committees this year have introduced PBM legislation, and the Federal Trade Commission (FTC) last year opened an investigation into the business practices and consolidation of PBMs.

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Mark Cuban Cost Plus Drug Co. Will Sell Branded Janssen, IBSA Drugs

Mark Cuban Cost Plus Drug Co., the wholesale, direct-to-consumer drug manufacturer and pharmacy launched by the eponymous entrepreneur, will sell brand-name diabetes drugs from Janssen, a division of Johnson & Johnson. Cuban also says that the company will soon sell hypothyroidism treatment Tirosint (levothyroxine). The drugs are the first brand-name products to be sold by the company, which has previously focused exclusively on generics; Cuban says that the company plans to sell whatever brand-name drugs that it can, depending on drugmakers’ interest.

Invokana (canagliflozin), Invokamet (canagliflozin-metformin HCl) and Invokamet XR (canagliflozin-metformin HCl) are now available from the startup, according to an April 3 tweet. Invokana will cost $243.90 for a 30-day supply, while Invokamet and Invokamet XR will each cost $244.20 for a 60-day supply. During a March 23 panel on prescription drug pricing and policy convened by Vanderbilt University, Cuban said that he doesn’t expect to stop at offering just a few brand-name drugs.

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© 2024 MMIT

Rx Oversight Issues at Federal Workers’ Comp Program Endangered Patients, Audit Says

The failure of a federal workers’ compensation program to properly manage prescription drug use and costs resulted in approximately $321 million in overspending on medications and “claimants receiving thousands of inappropriate prescriptions and potentially lethal drugs” like fentanyl, according to a new report from a government watchdog agency.

The Office of Workers’ Compensation Program (OWCP) said in the report, which reviewed data from fiscal years 2015-2020, that its hiring of a PBM in 2021 will address many of the concerns identified by auditors. But one consultant who participated in the audit contends that move will “absolutely not” fix the myriad oversight issues that were uncovered. In addition, the PBM’s contract does not require it to share any drug rebates with the Federal Employees Compensation Act (FECA) program — which makes the program an “outlier” among other federal payers, Joseph Paduda tells AIS Health, a division of MMIT.

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© 2024 MMIT

Senate Could Pass PBM Reforms This Year

Congressional interest in PBM reform may turn into comprehensive legislation as soon as this summer, D.C. insiders tell AIS Health, a division of MMIT, and possibly has enough bipartisan support to pass both chambers. Lobbyists representing employer plan sponsors say that measures including a requirement that PBMs be fiduciaries to plan sponsors and members, a federal ban on spread pricing, and mandatory price transparency disclosures are all under serious discussion.

Several Senate committees have made moves to advance PBM legislation. The Finance Committee held a hearing on PBMs at the end of March; the Commerce Committee has advanced legislation; and the Health, Education, Labor and Pensions (HELP) Committee seems poised to mark up legislation this month, according to press reports. In the Senate, which is controlled by Democrats, several bills have sponsors from both parties, and the HELP Committee markup will feature members of both parties, led by committee chair Sen. Bernie Sanders (I-Vt., who caucuses with Democrats) and ranking member Sen. Bill Cassidy (R-La.).

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Mark Cuban Cost Plus Drug Co. Will Sell Branded Janssen, IBSA Drugs

Mark Cuban Cost Plus Drug Co., the wholesale, direct-to-consumer drug manufacturer and pharmacy launched by the eponymous entrepreneur, will sell brand-name diabetes drugs from Janssen, a division of Johnson & Johnson. Cuban also says that the company will soon sell hypothyroidism treatment Tirosint (levothyroxine). The drugs are the first brand-name products to be sold by the company, which has previously focused exclusively on generics; Cuban says that the company plans to sell whatever brand-name drugs that it can, depending on drugmakers’ interest.

Invokana (canagliflozin), Invokamet (canagliflozin-metformin HCl) and Invokamet XR (canagliflozin-metformin HCl) are now available from the startup, according to an April 3 tweet. Invokana will cost $243.90 for a 30-day supply, while Invokamet and Invokamet XR will each cost $244.20 for a 60-day supply. During a March 23 panel on prescription drug pricing and policy convened by Vanderbilt University, Cuban said that he doesn’t expect to stop at offering just a few brand-name drugs.

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© 2024 MMIT

News Briefs: Express Scripts to Revamp Administrative Fees

The Cigna Group’s PBM, Express Scripts, on April 13 unveiled a “fully transparent pricing model” called ClearCareRx, which allows private sector and government employers as well as health plans to “pay exactly what Express Scripts pays for drugs.” That means clients will receive 100% of drug rebates that Express Scripts negotiates and will pay “one simple fee” to cover PBM services, the administration of pharmacy benefits, reporting and analytics, the company said. Express Scripts also rolled out what it’s calling the Copay Assurance Plan, which caps copays on prescription drugs: no more than $5 for generics, $25 for preferred brand drugs, and $45 for preferred specialty brand drugs for consumers enrolled in the program.

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Patient-Paid Prescriptions Are Challenging Traditional Industry Model

As the use of patient-paid prescriptions continues to grow, it is posing a challenge to the pharmacy benefit market, contended longtime industry expert Adam J. Fein, Ph.D., CEO of Drug Channels Institute, during a recent webinar. And with some industry developments such as the Inflation Reduction Act likely to impact the uptake of high-price/high-rebate drugs, patient-paid prescriptions could become an even bigger disruption within the market than they already are.

The issue of patient-paid prescriptions — which include both cash-pay claims and discount-card claims — is “potentially something that’s going to actually be genuinely disruptive, actually something that could change the structure of both the PBM industry and how plan sponsors” think about benefit design, Fein asserted. Both approaches, he explained, remove the third-party payer, allowing patients to make a transaction directly with a pharmacy.

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Study Suggests Part D Payers’ Prior Authorization Policies for New Drugs May Be Too Strict

Most new drugs covered under Medicare Part D are subject to prior authorization (PA) requirements, largely due to their high launch prices. A recent study published in JAMA Health Forum observed that these policies are frequently inconsistent across payers and may prove too burdensome for patients and providers.

Researchers identified drugs approved between 2013 and 2017 and reviewed the 2020 formularies of the eight largest Part D payers, which cover about 90% of all Part D beneficiaries. They compared PA policies to each drug’s FDA-approved indications and noted if payers mirrored the approved labeling or were more restrictive than the drug’s label. Researchers observed substantial variation in the frequency and type of PA across payers, and they found that about 40% of the new drugs had PA criteria that went beyond the drug’s labeling.

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News Briefs: Ohio AG Sues ‘Modern Gangster’ PBMs

Ohio Attorney General Dave Yost filed a lawsuit accusing The Cigna Group’s Express Scripts, Blue Cross Blue Shield-owned Prime Therapeutics, Humana Pharmacy Solutions and Ascent Health Services of colluding to “illegally drive up drug prices” and push those higher costs onto patients. In a March 27 press release, Yost called PBMs “modern gangsters” who have been “scheming in the shadows to control drug prices on all sides of the market” rather than using their negotiating power to drive down prescription costs, as advertised. The suit accuses the PBMs of multiple violations of the Valentine Act, Ohio’s antitrust law, and was filed in the Delaware County Common Pleas Court. “In the case of Express Scripts, the company added insult to injury when it responded to mounting public criticism of PBMs by forming the ‘group purchasing organization’ Ascent Health Services in 2019 — purportedly to take over the company’s pricing and rebate negotiations with drug manufacturers,” Yost’s press release stated.

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© 2024 MMIT