Drug Coverage

In an interview, James D. Chambers, Ph.D., from Tufts Medical Center, talks about the factors that are impacting the biosimilar market.

A survey by PSG has found that the pressure to control drug costs is leading some payers to look into unbundling pharmacy benefits as a way for better control.

Switching to Humira biosimilars saved Navitus clients more than $315 million in upfront costs in 2024 and resulted in a 60% reduction in net costs per claim.

The pharmacy benefit manager (PBM) industry is under pressure to shift to models that avoid conflicts of interest and misaligned incentives.

State efforts are aiming to bring more disclosure and transparency to PBM practices, mandating certain pharmacy reimbursement levels, requiring 100% pass-through rebates, and prohibiting spread pricing.

Pharmacy costs and outpatient facility care generate 69% of the cost increase for 2025, according to Milliman’s recent Medical Index.

Health plan sponsors are also expected to see a reduction in the net cost per prescription of GLP-1 medications to treat obesity.

A new law in Iowa, if signed by the governor, will mandate 100% pass-through of rebates, increased financial transparency, and a minimal payment for pharmacies. Critics say it will be the most costly mandate in the state’s history.

It could improve access to community pharmacies and lower prices. Or it will limit access to critical drugs and impact payers’ ability to contract for a broad range of services. Industry leaders are unsure about the impact of Arkansas’ law banning PBMs from owning pharmacies.

Express Scripts, Cigna, UnitedHealthcare, CVS Caremark and Optum Rx are among the payers that have added Yesintek to their formularies.

Effective July 1, 2025, CVS Caremark will place Wegovy injection 2.4 mg as preferred on its commercial template formularies.

Insurance hurdles and the complexities of prior authorization create barriers to care, according to oncologists in a new survey by Sermo.

Novo Nordisk has teamed up with Hims & Hers Health, LifeMD and Ro for cash-paying patients to access Wegovy injection 2.4 mg through its NovoCare Pharmacy.

Giant Eagle also helped EmpiRx Health create a national pharmacy care network that was purpose-built for pharmacy and grocery chains.

Nationwide, 58% of Medicare beneficiaries living in rural areas are enrolled in stand-alone prescription drug plans in 2025.

A new paper by the Institute for Clinical and Economic Review (ICER) looks at the cost-effectiveness versus affordability issue of obesity medications such as Wegovy and Zepbound.

Bkemv is being offered at 10% off Soliris, and Epysqli is offered at 30% below Soliris. Both biosimilars treat several of the same rare immune diseases as Soliris.

Wegovy is also available through NovoCare Pharmacy, which directly ship all dose strengths at a cost of $499 per month for cash-paying patients.

Optum Rx's new cost-based program uses an internal algorithm that leverages multiple available industry data sources, such as NADAC and PAC, to inform reimbursement.

Optum Rx has eliminated reauthorization for almost 70 drugs for chronic diseases, about 10% of its overall pharmacy prior authorizations.

Steqeyma is one of seven Stelara biosimilars that have been approved by the FDA.

Lumicera Health Services, Navitus’ specialty pharmacy, has made a deal with Teva to offer an unbranded biosimilar that they estimate will save $112,000 and $336,000 per patient per year. Navitus will remove Stelara from formulary on July 1, 2025.

The new bill would also require state Medicaid programs to report National Average Drug Acquisition Costs (NADAC) as a way to increase transparency in drug pricing.

NovoCare Pharmacy will provide all dose strengths of Wegovy at a reduced cost of $499 per month for cash-paying patients without insurance.

The Institute for Clinical and Economic Review has prepared a special report on Trelegy and Breo, two therapies that treat patients with chronic obstructive pulmonary disease that are part of CMS's drug price negotiation program.

Selarsdi and Yesintek have launched this month at prices that are 85% and 90% off the cost of Stelara.

Blue Cross Blue Shield of Michigan said it is evaluating any potential updates to the coverage process for Darzalex Faspro and there are no changes at this time.

The new lower prices apply to some doses of Zepbound provided in vials but not the autoinjector pens.

There are four biosimilars of Stelara available to treat chronic autoimmune diseases — Wezlana, Selarsdi and now Pychiva and Yesintek.

Teva and Alvotech are introducing Selarsdi at an 85% discount off the reference product Stelara. Selarsdi is available as a subcutaneous injection and for intravenous infusion.