Drug Coverage

Just as Andrew Witty of UnitedHealth Group did in a call with investors last month, CVS Health’s CEO David Joyner defended the role of PBMs in healthcare.

Trump has reversed some of President Biden’s initiatives, including $2 monthly out-of-pocket cap on some generics and experimental pricing models for gene therapies. But so far the healthcare elements of the Inflation Reduction Act remain unchanged.

CEO Andrew Witty promised that UnitedHealthcare would work to speed up turnaround times for approval of some procedures and services in Medicare Advantage plans.

Ozempic, Rybelsus and Wegovy top the list of the newest drugs selected for Medicare Part D price negotiation, part of the Inflation Reduction Act.

In an investor call, Andrew Witty promised full transparency and 100% pass-through rebates for prescription drugs by 2028.

UnitedHealth Group reported a medical care ratio in 2024 of 85.5% compared with 83.2% in 2023.

The Federal Trade Commission suggests that PBMs profit from specialty generic drugs such as those for cancer and HIV and steer patients to their own pharmacies.

Effective Jan. 1, 2025, Independence Blue Cross has begun excluding coverage for 18 months for therapies — but not cancer drugs — that have an accelerated approval based on a surrogate endpoint.

The Institute for Clinical and Economic Review assessed the formularies of 11 payers, covering 57 million people, to determine access for drugs that the organization had reviewed in 2022 for cost-effectiveness.

A new bill in Congress would require pass-through prices in both Medicare, and Medicaid and require transparency of PBM practices in the commercial space.

In 2023, there was lower net spending and prices on adalimumab, which was likely because of rebates from AbbVie, Humira’s manufacturer, a new analysis finds.

The Institute for Clinical and Economic Review has identified five drugs — Biktarvy, Darzalex, Entresto, Cabometyx, and Xeljanz — with prices increases that are not supported by new clinical evidence, with a total of $815 million in added costs to U.S. payers in 2023.

Beginning in January 2025, Optum Rx will remove from several Humira biosimilars from its formulary, including Hyrimoz (adalimumab-adaz), the unbranded Hyrimoz and Cyltezo (adalimumab-adbm).

The biggest advantage of suzetrigine would be that it helps patients avoid the use of opioids for acute pain. The FDA’s goal date for suzetrigine is Jan. 30, 2025.

Whether this proposed rule actually has any impact remains to be seen, especially with a new administration led by Donald Trump’s new health appointees.

CVS Caremark has removed several diabetes drugs favor of newer products and generics, and is even favoring an insulin infusion system developed by a company that was cofounded by Alan Lotvin, a former executive at CVS Health.

Monjuvi is available under an accelerated approval to treat adults with relapsed or refractory diffuse large B-cell lymphoma.

Almost half of those surveyed by Navitus Health Solutions said they’ve been unable to fill a needed prescription because of cost.

For the first time, Skyrizi has replaced Humira as AbbVie’s sales driver, largely due to companies encouraging “product hopping” to avoid competition, creating concerns for the sustainability of the burgeoning adalimumab biosimilar market.

In the ESSENCE trial, semaglutide improved liver fibrosis in patients with metabolic dysfunction-associated steatohepatitis (MASH).

ICER has given tabelecleucel a rating of A, indicating the T cell therapy for Epstein-Barr virus related post-transplant lymphoproliferative disease has a high certainty of substantial net health benefit and would be cost-effective if priced between $143,900 and $273,700.

Qsymia’s manufacturer also released postmarketing data showing the oral therapy for weight loss was associated with reductions in 24-hour mean systolic blood pressure.

PBMs are putting weight loss drugs, including Wegovy and Zepbound, on their national formularies, but coverage by plans is uneven. What is needed is more data about whether these drugs can lower overall healthcare costs.

The IQVIA analysis finds that the impact of drug price negotiation on patients’ out-of-pocket spending could also be smaller than expected.

Sanjula Jain of Trilliant Health talks about how employers are best positioned to demand value for money from the U.S. healthcare system.

UnitedHealthcare is adding deductibles to Part D prescriptions on certain formulary tiers as a result of plan design changes from the Inflation Reduction Act.

Blue Shield of California is purchasing Idacio for a net price of $525 per monthly dose, and most plan members will pay $0 out of pocket.

PSG's Morgan Lee talks about how customers of the Big 3 PBMs report lower satisfaction across most measures, and they are less likely to recommend their PBM.

The FTC said it is focusing on insulin as the “poster child” of a broken system, where PBMs leverage formulary placement to receive higher rebates from pharmaceutical manufacturers.