Drug Coverage

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.

GeneCQ uses integrated medical and pharmacy claims data to provide insight into the exposure to the costs for gene therapies.

When CMS begins negotiations for physician-administered drugs under the Inflation Reduction Act, providers, including those whose services are covered by commercial insurance, could see lowered reimbursement.

Whether Express Scripts wins its unique defamation lawsuit will depend on whether the PBM can prove the FTC made false statements. But winning the lawsuit may not be what the PBM is looking for.

Express Scripts alleges in its suit that the FTC followed “prejudice and politics, not evidence or sound economics,” and that there is no support for the assertion that the power of PBMs has increased over time.

The new program, which begins in January 2025, provides members of Prime Therapeutics support for navigating utilization management requirements and finding financial assistance.

The Inflation Reduction Act’s limit on Medicare Part D spending can lead to savings for patients prescribed oral chemotherapy drugs.

This analysis finds that 57.4 million adults under the age of 65 could potentially be eligible for GLP-1 drugs based on currently approved FDA indications, including 36.2 million people with obesity.

The IQVIA vice president and frequent speaker at pharmacy and managed care meetings said he will retire in May 2025.

The private-label biosimilar will be available at an 80% discount off Stelara. Evernorth has not released information about which company will be producing the biosimilar.

The growth of out-of-pocket and insurer/negotiated prices paralleled one another until 2016 when negotiated and insurer prices began declining

MedImpact is not requiring patients currently taking Humira to switch, and all three products are on a preferred tier.

Zymfentra is a subcutaneous infliximab product used to treat ulcerative colitis and Crohn’s disease. It has a price of $6,181.08 for two shots over four weeks.

The monthly price of the 2.5 mg Zepbound single-dose vial is $399 and the 5 mg dose is $549, which Lilly officials said is in line with the savings program for without insurance.

Beginning in 2025, Express Scripts will favor biosimilars of Humira, including its own private-label version.

Avalere’s Kylie Stengel talks about the regional shifts in formularies and utilization management in Medicare Part D prescription drug plans.

Prademagene zamikeracel is a cell therapy in development to treat patients with recessive dystrophic epidermolysis bullosa (RDEB), a rare connective tissue disorder.

Zymfentra launched in March 2024 as the first subcutaneous formulation of infliximab for patients with ulcerative colitis and Crohn’s disease. It has a list price of $6,181.08 for two shots over four weeks.

No information, however, is available about which insurance plans are providing coverage of Anktiva or what the utilization management requirements are.

New analysis shows that differences in the methods used to set drug payment amounts under Part B versus under Part D result in different payment amounts for the same drugs.

In a recent survey, payers said their priorities include addressing the impacts of Medicare’s Drug Price Negotiation Program and the Part D redesign.