Drug Coverage

Beginning in January 2024, if GoodRx shows a lower CVS price than a member’s plan price, that lower price will automatically be given.

About half of Navitus’ commercial clients saw a drug spend decrease compared with 2021.

Governor Phil Murphy has signed three pieces of legislation that would require PBMs to use prescription drug rebates to lower premiums and out-of-pocket costs for consumers and prevent the practice of spread pricing.

Express Scripts will also add Sandoz’s unbranded version of adalimumab to its National Preferred Formulary. The Humira biosimilar Amjevita was added previously.

Medicare will cover Alzheimer’s drugs with full approval, including Leqembi — if the physician and patient participate in a real-world registry trial to gather additional data.

RxPreferred will offer Yusimry, a biosimilar of Humira, at a price of $569.27 plus dispensing and shipping fees. This price represents a 92% discount off Humira’s monthly price.

Most of the Humira biosimilars are available with two pricing options. Of the larger PBMs, only Optum Rx so far has weighed in on a coverage decision.

Similar to Amgen’s Amjevita, Hulio will be offered at a list price of 5% below and 85% below the current Humira list price.

The increase is expected to be somewhat offset by the impact of biosimilars coming to market and more care being provided in outpatient settings.

How the insurance industry denies claims; consumers confused by complexity and red tape; and how the ALS drug Relyvrio came to be.

Recent study finds that Medicaid coverage for some of the first gene and cell therapies was at times delayed and not consistent with federal requirements.

A carton of Hadlima including two pre-filled pens or two pre-filled syringes is available at a list price of $1,038.

In the revised guidance, CMS clarified aspects of the negotiation process and outlined additional opportunities for engagement during the process. CMS will publish by Sept. 1, 2023, the list of the first 10 drugs for price negotiation.

Biosimilars have the potential to lower costs, but the adoption has been slower than expected, a recent study finds.

Sarah Emond will continue with ICER’s efforts to assess drug cost-effectiveness and health plan access policies that began with founder Steve Pearson, M.D., who will transition to an advisor role in 2024.

The National Alliance of Healthcare Purchaser Coalitions has issued a playbook to help companies navigate what they see as a flawed PBM contracting model and lack of competition.

Optum Rx will include the three biosimilars on its standard formulary at parity with Humira.

Employers and plans need to prioritize clinical efficacy over drug price, look for price reductions — and not rebates — on biosimilars, and advocate for a public option to cover gene therapies. These are just a few of ideas that consultant Alex Jung put forward at a meeting of the Midwest Business Group on Health.

About a quarter of those surveyed said their insurance didn’t cover a needed prescription drug or charged a very high copay.

If passed, PBMs would not be able to charge fees that are connected to the price of a drug, discounts, or rebates.

Ozempic, Wegovy and other GLP-1 drugs present a challenge to payers in terms of costs and outcomes, finds PSG’s new Drug Benefit Design Report.

SmithRx will offer Yusimry through Mark Cuban’s online pharmacy for $569.27, and members will be able to apply their insurance benefits.

Renee Rayburg talks about how paying for specialty drugs continues to be a top concern for both health plans and employers.

The median annual cost for new oncology medicines launched in 2022 was $260,000, up from $63,534 10 years ago, an IQVIA report finds.

In an analysis, researchers determined that Inpefa is cost-effective at commonly accepted willingness-to-pay thresholds in treating patients with heart failure who have diabetes.

The drugs must have full “traditional” FDA approval and patients need to be enrolled in a registry that collects post-approval data efficacy and safety when the drugs are used in clinical practice.

Coherus will launch Yusimry in July with a list price of $995 per carton (2 x 40 mg/0.8 mL autoinjectors); “the lowest price announced to date of any adalimumab offering in the United States,” the company said.

Miebo is the first and only prescription eye drop approved for dry eye disease (DED) that directly targets tear evaporation.

The frequency of drug manufacturer coupon utilization is associated with more market competition—but not patients’ out-of-pocket costs.

Despite having a highly differentiated clinical value proposition compared to branded, twice-nightly oxybates, Avadel is pricing Lumryz at $64.67 per gram or around $177,034 annually, which is on par with twice-nightly oxybate products that require chronic, middle-of-the-night awakening.