Drug Coverage

While ICER found that overall major payer coverage policies are in line with the organization’s fair access criteria, many payers do not provide adequate transparency into clinical coverage criteria.

A new membership program, SmartRx, offers consumers savings on prescriptions, as well as office visits, eye care, vaccines and pet meds.

Lawsuit accuses the companies of using unlawful, unfair, and deceptive practices.

Optum Rx’s Humira biosimilar strategy for 2023 was set up to allow for the most value in the first year, said CEO Heather Cianfrocco.

CMS officials plan to engage with the public for feedback and insights as they implement the Medicare Drug Price Negotiation Program.

With this partnership, employers and their members using RxPreferred for their pharmacy benefit will have access to all medications available through Cost Plus Drugs.

Soleo Health will distribute Leqembi, the newly approved Alzheimer's therapy, to provider offices and infusion centers, as well as administer it across its own ambulatory infusions centers.

Synergie Medication Collective, which launches this month, is focused on improving affordability and access to gene therapies, infusible cancer drugs and other medications administered in a clinical setting.

List prices of 450 medications have increased 5% overall at the beginning of 2023. More price hikes are expected.

An integrated approach helped Regence drive conversion to biosimilars with a 95% member utilization.

Among the most-read stories about PBMs include Transcarent and Prescryptive Health teaming up for employer pharmacy; Kroger Health ending agreement with Express Scripts; Mark Cuban Cost Plus Drugs teaming up with EmsanaRx and Vivio Health; and Abarca Health takes on a challenging implementation.

Drug coverage decisions and new offerings from OptumRx, Caremark, Cigna and Wellcare made the list of the top-read drug coverage news in 2022.

ICER analysts remain uncertain about using amyloid removal as a surrogate marker for clinical benefit in Alzheimer’s disease.

Rezlidhia is an oral, small molecule inhibitor of mutated IDH1 that was approved by the FDA to treat patients with relapsed or refractory acute myeloid leukemia.

The monoclonal antibodies that treat patients with multiple sclerosis would have to be priced more than 50% lower to meet the common standards of cost-effectiveness, according to the Institute for Clinical and Economic Review.

Researchers modeling the cost-effectiveness of chimeric antigen receptor T-cell therapy (CAR-T) therapy and antibody conjugate found that they fell short.

Smaller and midsize pharmacy benefit managers are taking on Optum Rx, CVS Caremark and Express Scripts. They say they have better technology and are more transparent about their pricing.

A decision is anticipated in early January about which of the now eight Humira biosimilars will be included.

Prescryptive will offer a subscription-based program for employers that aims to provide a more predictable benefit for companies and their employees.

The Medicare Part D Senior Savings Model — a CMS effort to test $35 copays for insulin — led to lowered total costs for beneficiaries.

Magellan Rx predicts oncology and high-cost rare disease treatments will continue to drive medical pharmacy spend in commercial, Medicaid and Medicare.

Low-income subsidies can eliminate much of the out-of-pocket costs that patients must pay.

The EmsanaRx Plus program is connecting employers to the discounted drugs offered through Mark Cuban Cost Plus Drug Company. The program will be available beginning March 1, 2023

Cost savings were not associated with an increase in adverse drug events.

Independent pharmacies are no longer part of Tricare’s pharmacy network for uniformed service members and their families. The pharmacy groups say this will impact 400,000 beneficiaries.

Health insurance premiums, especially in the ACA Marketplace, could increase if the federal government ends purchasing of COVID-19 vaccines and boosters.

Seven of the 10 top selling drugs with high price increases lack the clinical evidence to justify those increases.

Cigna and Express Scripts have not yet made a decision about which of the Humira biosimilars will be included but they will evaluate all products in the coming months.

Doctors surveyed by the Association for Clinical Oncology said payer prior authorization can cause disease progression and loss of life.

The reference to “maximum fair price” in the act bodes poorly for manufacturers and suggests more of a take-it-or-leave-it situation rather than a negotiation where clinical evidence would be the prevailing factor in determining price.