When benefits managers from a range of employers gathered at the Midwest Business Group on Health’s (MBGH) recent forum in Chicago, the final session of the day revealed that specialty drugs were some of their top concerns. And it appears employers are getting savvier about managing them.

A big focus of the conference was benefits managers’ fiduciary duty to their employees — and how shirking that duty could land them in hot water.

“If you haven't done a market check, do a market check,” recommended Dan Dentzer, manager of health and wellness design for United Airlines, at the June 26 MBGH Employer Forum on Pharmacy Benefits, Specialty and Biopharma Therapies. “I do market checks like I change my socks because you have to know what's going on out there. You have to know what others are doing. You have to know you're getting the best deal possible. If you haven't done that, please do.”

Testifying before a House committee on July 23, executives of the three largest PBMs faced a grilling from lawmakers while trying their best to outline the reforms and transparency efforts they’ve voluntarily implemented in their businesses.

However, the executives’ answers to questions about group purchasing organizations (GPOs), especially when compared to their answers to similar questions at a 2023 hearing, suggest that the companies may still be resisting transparency in some respects.

As scrutiny of PBMs has reignited recently — with critics of the industry hoping to push through a reform measure by the end of the year and the Federal Trade Commission (FTC) reportedly poised to sue the largest PBMs over their contacting practices — the spotlight is also getting brighter on GPOs.

GoodRx, Inc. has dipped its toes into the booming Humira (adalimumab) biosimilar market with the help of Boehringer Ingelheim (BI), which will offer patients its Cyltezo (adalimumab-adbm) interchangeable adalimumab biosimilar direct to patients through GoodRx. Experts say that while GoodRx is another welcome entrant to the Humira biosimilar fray, the deal is unlikely to capture GoodRx or BI a great deal of market share.

According to a July 18 press release, BI and GoodRx now offer both high- and low-concentration Cyltezo to "anyone with a valid prescription, regardless of insurance status...at over 70,000 retail pharmacies nationwide," at an "exclusive cost" of $550 per two-pack of auto injectors or pre-filled syringes. The companies say that this price "represents a 92% discount from the Humira list price."

CVS Health Corp.'s Caremark will pay at least $45 million to the state of Illinois to settle accusations from the state's attorney general, Democrat Kwame Raoul, that the PBM didn’t pass through rebates to the state's health plans. According to a June settlement document obtained by STAT, Raoul accused CVS of "unlawfully depriv[ing] the state" of owed rebates negotiated with manufacturers for prescription drugs. CVS denied mishandling the rebates but still agreed to settle the case.

Vermont Attorney General Charity Clark, a Democrat has filed a lawsuit against The Cigna Group’s Evernorth and Caremark. A July 17 press release alleges that the two PBMs “grant placement on their standard formularies to the prescription drugs with the largest payments from manufacturers and the highest list prices, while excluding lower-cost prescription drugs.” Clark is just the latest state attorney general to target PBMs. Among others, Arkansas Republican Attorney general Tim Griffin recently sued UnitedHealth Group’s Optum Rx and Evernorth over their alleged roles in the opioid epidemic. And in 2023, Ohio Attorney General Dave Yost filed a lawsuit accusing Express Scripts, Prime Therapeutics, Humana Pharmacy Solutions and Ascent Health Services of colluding to drive up drug prices.

Another state attorney general, Vermont Democrat Charity Clark, has filed a lawsuit against prominent PBMs — in this case, The Cigna Group’s Evernorth and CVS Health Corp.’s Caremark. According to a July 17 press release from Clark’s office, the two PBMs “control approximately 95% of the commercial market in the state” and “as a result, they have a hand in nearly every prescription transaction and have near complete control over the pricing, dispensing, and reimbursement systems.” The press release alleges that the two PBMs “grant placement on their standard formularies to the prescription drugs with the largest payments from manufacturers and the highest list prices, while excluding lower-cost prescription drugs.” Arkansas Republican Attorney general Tim Griffin recently sued UnitedHealth Group’s Optum Rx and Evernorth over their alleged roles in the opioid epidemic. And in 2023, Ohio Attorney General Dave Yost filed a lawsuit accusing Express Scripts, Prime Therapeutics, Humana Pharmacy Solutions and Ascent Health Services of colluding to drive up drug prices.

White bagging continues to be a sore subject for providers, according to a June 21 Avalere Health report. As in past reports, providers surveyed by Avalere are concerned that white bagging can harm patients and lead to wasted medication — which can add up, since payers only use white bagging strategies for expensive specialty medications. The report also raised concerns that payer ownership of specialty pharmacies raises conflicts of interest and could accelerate provider consolidation.

White bagging is a payer practice that significantly changes the customary dispensing and billing arrangements around provider-administered drugs. Until recently, providers used the “buy-and-bill” framework with regard to such drugs. In buy-and-bill transactions, which still account for the vast majority of specialty pharmacy care, providers purchase a specialty drug, stock it in their facility and charge a payer for it after administering the drug to a patient.

Blue Shield of California caught the attention of the industry last August when it announced a switch to a pharmacy benefits model using five vendors. While some insurers and plan sponsors have considered a similar move following Blue Shield’s revelation, benefits consultants tell AIS Health, a division of MMIT, that most payers continue to have a traditional arrangement where one PBM handles all pharmacy-related activities. They add that Blue Shield’s so-called unbundled approach could be difficult to manage and may not achieve significant cost savings.

A survey released last month from the Pharmaceutical Strategies Group (PSG) found that 72% of health plan respondents had heard about Blue Shield of California’s change. Morgan Lee, Ph.D., PSG’s senior director of research and strategy and one of the report’s authors, noted during a June 18 webinar that the survey was conducted in February and March. As such, “we’ll probably continue to see [awareness of unbundling] increase over time,” Lee said.

When the Federal Trade Commission on July 9 released an interim report based on its yearslong investigation of PBMs, criticism of the document abounded, with even an FTC Commissioner saying it wasn't nearly comprehensive enough to publish. However, one day later the FTC appeared to prove its critics wrong, with the Wall Street Journal reporting that it plans to sue the three largest PBMs over their business practices related to the rebates they negotiate with drug manufacturers for products like insulin.

The FTC has not yet confirmed the WSJ report, which cited a person familiar with the matter. But it would not be the first time the federal government attempted to reform how PBMs treat drug rebates. The Trump administration proposed a rule in 2019 that would have effectively forced PBMs to pass negotiated rebates on to consumers at the point of sale in Medicare Part D and managed Medicaid, but it later tabled the regulation.

When the Federal Trade Commission (FTC) on July 9 released an interim report based on its yearslong investigation of PBMs, criticism of the document was in no short supply.

The trade group representing major PBMs, the Pharmaceutical Care Management Association (PCMA), said the report “falls far short of being a definitive, fact-based assessment of PBMs or the prescription drug market.” And FTC Commissioner Melissa Holyoak, who voted against issuing the report, said during a House Energy & Commerce Committee hearing on July 9 that the report is not nearly comprehensive enough and “lacks economic and empirical evidence.”

Although the Supreme Court has already weighed in on one case regarding states’ ability to regulate PBMs, the top law enforcement officials in more than 30 states are asking the high court to review another case that they claim will remove lingering uncertainty about the limits of states’ authority.

In PCMA v. Mulready, the current case, the Pharmaceutical Care Management Association is challenging an Oklahoma law — the Patient’s Right to Pharmacy Choice Act — which sets geography-based access standards for pharmacy networks. Among other provisions, it also bans PBMs from using discounts or cost-sharing differences to push plan members to certain in-network pharmacies, particularly those owned by that same PBM’s parent company.