Drug Coverage

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.

Just as Andrew Witty of UnitedHealth Group did in a call with investors last month, CVS Health’s CEO David Joyner defended the role of PBMs in healthcare.

Trump has reversed some of President Biden’s initiatives, including $2 monthly out-of-pocket cap on some generics and experimental pricing models for gene therapies. But so far the healthcare elements of the Inflation Reduction Act remain unchanged.

CEO Andrew Witty promised that UnitedHealthcare would work to speed up turnaround times for approval of some procedures and services in Medicare Advantage plans.

In an investor call, Andrew Witty promised full transparency and 100% pass-through rebates for prescription drugs by 2028.

UnitedHealth Group reported a medical care ratio in 2024 of 85.5% compared with 83.2% in 2023.

The Federal Trade Commission suggests that PBMs profit from specialty generic drugs such as those for cancer and HIV and steer patients to their own pharmacies.

Effective Jan. 1, 2025, Independence Blue Cross has begun excluding coverage for 18 months for therapies — but not cancer drugs — that have an accelerated approval based on a surrogate endpoint.

The Institute for Clinical and Economic Review assessed the formularies of 11 payers, covering 57 million people, to determine access for drugs that the organization had reviewed in 2022 for cost-effectiveness.

A new bill in Congress would require pass-through prices in both Medicare, and Medicaid and require transparency of PBM practices in the commercial space.