Drug Coverage

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.

SelfJect is priced at parity with the Acthar Gel multi-dose vial and syringe.

Cigna officials cite significant growth in Evernorth Health Services and Express Scripts for the increase in revenue.

CVS Caremark is requiring step therapy through a generic prescription proton pump inhibitor before providing coverage.

Higher costs per claim, coupled with an increased number of patients using specialty drugs, has contributed to higher spend.

Boehringer Ingelheim’s high- and low-concentration adalimumab-adbm will be available through GoodRx for $550 for two-pack, which represents a 92% discount from the Humira list price.

The switch to biosimilars helped Navitus clients offset increased utilization in the non-specialty category and the introduction of higher-cost specialty drugs.

The FTC’s interim report on pharmacy benefit managers (PBMs) was just the latest effort to highlight what some say is an industry that profits at the expense of patients and independent pharmacists. The PBMs say the report paints an incomplete, misleading picture. Others say it shows the FTC is prepping its antitrust case.

The PBM industry said the FTC has not been objective, and that efforts to limit PBM negotiating tools would put patients at the mercy of drug manufacturers.