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News Items, by Subject

Health plan costs - prescription drugs

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[Opinion] National Health Law Program Comments on HHS Plan to Lower Drug Prices
"[National Health Law Program (NHeLP)] outlines steps HHS can take to lower consumer out-of-pocket expenses, such as barring the use of co-insurance whereby insurers require consumers to pay a percentage of the costs for prescription drugs ... And [NHeLP's] comments describe a number of measures to curb pharmaceutical company profiteering on the backs of health care consumers and tax payers." (National Health Law Program [NHeLP])
Pfizer Backs Down from Drug Price Hike After Pummeling by Trump Administration
"In a surprising reversal, pharmaceutical giant Pfizer said [July 10] it would back down from planned price hikes for several dozen of its drugs amid heavy criticism from the White House. After weathering a one-two punch Monday from the president and his [HHS] secretary, who took turns publicly lambasting the company, Pfizer appeared to have escaped unscathed, at least in terms of its performance on Wall Street." (HealthLeaders Media)
HHS Secretary Says Changes Are Coming in Bid to Get a Handle on Drug Prices
"[HHS] Secretary Alex Azar promised a hospital industry group ... that changes are coming to the popular drug discount program known as 340B.... In particular, he said, further oversight is needed to improve transparency to ensure the program benefits patients, not hospitals. But Azar offered few details on what specific changes the agency is considering for the 340B program." (FierceHealthcare)
Specialty Drug Coverage Varies Across Commercial Health Plans
"Across 3,417 decisions, 16 percent of the 302 drug-indication pairs were covered the same way by all of the health plans, and 48 percent were covered the same way by 75 percent of the plans.... Health plans restricted coverage of drugs indicated for cancer less often than they did coverage of drugs indicated for other diseases.... Variations in coverage have implications for patients' access to treatment and health system costs." (Health Affairs)
What Does a Drug Cost? It Depends on Where You Live
"Some disparities obviously result from a higher cost of living -- New York and San Francisco were the most expensive cities in the country for drugs. But prices can vary widely even between similar cities in the same state: Cleveland's pharmacy prices were 2.5 percent above the national average, while not far away, Columbus had prices that were nearly 22 percent below average. In Cleveland, the generic version of Paxil, the antidepressant, costs about $46.94, while in Columbus, someone would pay $20.87." (The New York Times; subscription may be required)
[Opinion] When Amazon Sneezes, the Health Insurance Industry Catches a Cold
"Once again, a move by Amazon has cut billions of the health insurance industry stock market value. When Amazon, Berkshire Hathaway and JPMorgan announced a partnership to control healthcare costs, health insurers were devalued. This time, with the announced purchase of PillPack, the pharmacy benefit managers (PBMs) shed a fast approximately $11 billion." (Frenkel Benefits)
Pfizer Raises Prices for Dozens of Drugs
"Pfizer Inc. raised the list prices for more than 40 of its prescription drugs this week, marking a second round of increases this year despite mounting public scrutiny.... Many lift the list prices by 9.4% and by double-digit percentages for the year overall. The moves ... separate Pfizer from several rivals that have pledged to lift list prices only once every 12 months and by less than 10% overall for the year, as they try to blunt criticism and avoid congressional action." (The Wall Street Journal; subscription may be required)
Amazon's Attack on the Pharmacy Industry Has Begun
"The PillPack acquisition gives Amazon a foothold in the regulated pharmacy business. PillPack has pharmacy licenses in all 50 states and brings in-house expertise that could help Amazon move more quickly into a space filled with regulatory obstacles ... PillPack has also developed expertise in battling with payers and pharmacy benefit managers to have its services covered, and Amazon will bring new clout to those negotiations." (The Washington Post; subscription may be required)
Prescription Drug Costs Retirees Should Expect to Pay
"The majority of Medicare Part D plans (55 percent) have a deductible before medications will be covered.... Medicare Part D plans have a formulary, or list of covered medications. These medications are typically grouped into tiers that have different costs for plan participants.... Retirees who need to take medications classified as non-preferred brand name drugs or specialty drugs often need to pay coinsurance, or a percentage of the price of the medicine." (U.S. News & World Report)
How Employers Are Working to Combat the Opioid Epidemic
"[E]mployers have addressed [the opioid epidemic] through innovative plan design and outreach.... Developing best practices ... Tighter controls on opiod prescriptions ... Comprehensive patient education ... Attention to drug prescription and interaction guidelines ... Collaboration with physical and mental health care providers." (American Benefits Council)
Arkansas PBM Law Preempted by ERISA and Medicare Part D
"Act 900 attempted to set a floor to offset an industry trend in which pharmacies accepted reduced reimbursement rates for dispensed prescriptions ... as a result of participating in a PBM's preferred pharmacy network.... Act 900 also included a "decline-to-dispense" option if a pharmacy would lose money on a particular transaction.... The court relied on a recent Eighth Circuit decision in which the court held that an Iowa statute similar in purpose to Act 900 was ERISA-preempted ... The court observed that the law implicitly referenced ERISA by regulating PBMs in administering benefits for "covered entities," which necessarily included health plans." [Pharmaceutical Care Mgmt. Ass'n v. Rutledge, Nos. 17-1609, 17-1629 (8th Cir. June 8, 2018)] (Thomson Reuters Practical Law)
Price Check on Drug Ads: Would Revealing Costs Help Patients Control Spending?
"[W]hat is the right number to use? There is a dizzying array of ways to look at drug prices, including average wholesale and average sales prices.... Would the price be pegged to a monthly cost? A per-dose cost? Or, even more inscrutable, a 'unit cost,' which may not equal a single dose? ... The prices likely would not be what most consumers actually pay. Most patients with insurance typically shell out either a flat-dollar copayment or a percentage of the drug's cost. Some patients get coupons that can reduce their cost to zero." (Kaiser Health News)
No Magic Pill to Cure Specialty Drug Costs, But Here Are Some Preventive Measures
"Change where specialty drugs are administered ... Review your PBM contract.... Refer participants to patient and copayment assistance programs to receive financial help.... Establish a prior authorization program ... Encourage the use of lower cost alternatives.... Implement a care management program through which a care manager will work with participants taking specialty medications." (International Foundation of Employee Benefit Plans [IFEBP])
[Opinion] The CREATES Act: Stepping Closer to Drug Pricing Justice?
"The Creating and Restoring Equal Access to Equivalent Samples (CREATES) Act, a bipartisan bill currently in the Senate, attempts to address one of the most prevalent tactics being used today; the brand name drug manufacturer refuses to sell their drug to the competitor (which needs the drug to conduct bioequivalence testing, so it can safely replicate it for generic use) by twisting FDA safety requirements.... The CREATES Act would allow the generic drug manufacturer to sue the brand manufacturer, compelling it into providing samples of the drug." (Frenkel Benefits)
State Policies to Address Prescription Drug Prices
"[S]everal states have taken steps to address prescription drug prices ... [in] three major categories: improving price transparency; increasing state negotiating power; and cracking down on price gouging. The experiences of these states demonstrate potential promising paths forward for other states[.]" (Center for American Progress)
Administration Issues Request for Information on Drug Costs
"While the RFI focuses mostly on drug companies and federal health care programs, it also has important long term ramifications for insurers and PBMs, particularly with respect to drug rebates, as well as potentially for employers that obtain prescription drug services in connection with their group health plans." (Groom Law Group)
'Right to Try' Legislation Enacted; No Impact on Benefit Plans Expected
"The legislation does not mandate employer-sponsored plan coverage of drugs the FDA characterizes as investigational or experimental drugs. Indeed, most employer plans explicitly exclude those drugs from coverage.... [E]ven if a plan sponsor wanted to offer this type of coverage, doing so would pose administrative challenges. Prescription drugs must have FDA approval in order to have a national drug code (NDC), which is necessary for a pharmacy benefit manager or a pharmacy to process a claim." (Conduent)
The 'Right to Try' Bill: Beneath the Surface
"The 'Right to Try' bill doesn't specifically require plans to pay for experimental care, but things get a little murky from there. Who pays for hope and who pays for harm? ... Even if your plan excludes coverage for the off-label use of prescription drugs, will it end up paying for the treatment of serious side-effects and complications? Is there really any way to distinguish cause and effect at end of life? What was the result of the natural disease progression, and what was the result of an adverse reaction to the experimental medication?" (Chelko Center for Benefits Management)
Benefit Change Could Raise Costs for Patients Getting Drug Copay Assistance
"Under new 'copay accumulator' programs, the monthly copayments drug companies make don't count toward patients' plan deductibles or out-of-pocket maximums.... Once patients hit the annual limit on a drugmaker's copay assistance program, they're on the hook for their entire monthly copayment until they reach their plan deductible and spending limits." (HealthLeaders Media)
Origins of an Epidemic: Purdue Pharma Knew Its Opioids Were Widely Abused
"Purdue Pharma, the company that planted the seeds of the opioid epidemic through its aggressive marketing of OxyContin, has long claimed it was unaware of the powerful opioid painkiller's growing abuse until years after it went on the market. But a copy of a confidential Justice Department report shows that federal prosecutors investigating the company found that Purdue Pharma knew about 'significant' abuse of OxyContin in the first years after the drug's introduction in 1996 and concealed that information." (The New York Times; subscription may be required)
Costs for Seniors Jump as Generic Drugs Move to Higher Formulary Tiers in Part D Plans
"Senior citizens with Medicare prescription drug plans ... are paying more for generic prescriptions even as the market price of these drugs stays flat ... because, over time, the generic drugs are being placed on higher formulary tiers where patients pay more out-of-pocket costs. The number of generic prescription drugs placed on the least-costly lowest tier fell 53% between 2011 and 2015. This shift resulted in a 93% increase in total patient cost sharing for these drugs, or a total of $6.2 billion." (American Journal of Managed Care)
HHS Secretary Outlines Priorities to Implement President's 'Blueprint' to Lower Prescription Drug Prices
"[HHS Secretary Alex Azar] outlined regulatory steps that he could take without congressional action such as changing drug rebates or changes to Medicare reimbursement. The Food and Drug Administration released a list of companies believed to be delaying the introduction of generic drugs and [CMS] put health insurers on notice that it would not tolerate so-called 'gag clauses' in contracts that cause many consumers to pay more for drugs at the pharmacy counter. Meanwhile, addressing the nation's opioid epidemic remains the dominant health care issue on Capitol Hill." (Medliminal)
Prescription Drug Pricing: A Collection of Policy Briefs and Papers (PDF)
78 pages. "This compendium of briefs and policy options papers provides a quick, clear, easy-to-use, and impartial foundation for anyone seeking to understand what's behind the rising price of prescription drugs." (Health Affairs)
The New Drug Blueprint: What's In It for Employer Plans?
"Revisiting how rebates are handled won't necessarily lower drug prices and we think it's fair to assume that PBMs/insurers will make up any lost revenue in a different way. Check your PBM contract -- PBMs/insurers frequently include a provision that allows them to re-rate the contract in the event of a change in the laws and regulations around rebates.... If PBMs were identified as plan fiduciaries, they would be accountable for negotiating in the best interest of the plan and its members. This could certainly change the dynamics of current PBM relationships and, if adopted, keep PBMs from accepting certain types of payments from both manufacturers and health plans." (Mercer)
CMS Sends Clear Message to Plans: Stop Hiding Information from Patients
"[On May 17, CMS] sent a letter to companies that provide Medicare prescription drug coverage in Part D explaining that so-called 'gag clauses' are unacceptable, as part of the Administration-wide 'American Patients First' initiative to lower prescription drug costs." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
[Opinion] Trump Administration's Rx 'Blueprint' Will Need More Action Steps to Tackle Prices
"Despite its length, the blueprint does not address the main culprits driving U.S. drug prices. To start with, drug manufacturers too often game the system by filing frivolous patents to create 'thickets' around their products or by paying generic companies not to manufacturer cheaper versions.... In addition, the blueprint does not identify some of the most effective tools for improved competition and negotiation.... Many have pointed to the president's campaign promises, which called for allowing Medicare to negotiate drug prices and the importation of drugs from other countries. These ideas are notably missing from the blueprint." (The Commonwealth Fund)
Fact Sheet: CMS Drug Spending Dashboards
"CMS is highlighting year-over-year changes in per unit spending for individual drugs at both the drug and the manufacturer-level. CMS is also expanding the dashboards to include the majority of drugs prescribed under these programs.... The tools focus on average spending per dosage unit and change in average spending per dosage unit over time. They also display consumer-friendly information on drug uses and clinical indications as well as spending information on manufacturer(s) of the drugs[.]" (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
CMS Unveils Enhanced 'Drug Dashboards' to Increase Transparency on Drug Prices
"The dashboards are interactive online tools that allow patients, clinicians, researchers, and the public to understand trends in drug spending.... In 2012, Medicare spent 17 percent of its total budget, or $109 billion, on prescription drugs. Four years later in 2016, spending had increased to 23 percent, or $174 billion. In 2016, the drugs listed [in this news release] accounted for $39 billion in total spending by Medicare and Medicaid." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
[Opinion] Trump's Drug Pricing Speech Breaks Little New Ground, Largely Spares Industry
"The first immediate action calls on the FDA to 'evaluate the inclusion of list prices in direct-to-consumer advertising.' ... The second immediate action calls on [CMS] to update Medicare's drug-pricing dashboard 'to make price increases and generic competition more transparent.' ... The use of confidential rebates has become a central feature of our drug reimbursement system, and restricting or reducing their use would significantly change the ways in which drugs are distributed and reimbursed." (Health Affairs)
HHS to Resurrect Medicare Part B Price Bidding Program
"HHS Secretary Alex Azar announced May 14 that the agency plans to propose a program to merge some Part B drugs with Part D, where their prices could be negotiated, a major goal of Trump's plan to lower drug prices.... Such a program has been used before with poor results." (FierceHealthcare)
[Official Guidance] Text of Policy Statement and Request for Comments: 'HHS Blueprint to Lower Drug Prices and Reduce Out-of-Pocket Costs' (PDF)
45 pages. "The blueprint covers multiple areas including, but not limited to: [1] improving competition and ending the gaming of the regulatory process, [2] supporting better negotiation of drug discounts in government-funded insurance programs, [3] creating incentives for pharmaceutical companies to lower list prices, and [4] reducing out-of-pocket spending for patients at the pharmacy and other sites of care.... HHS seeks to identify when developed nations are paying less for drugs than the prices paid by Federal health programs, and correct these inequities through better negotiation.... Through this request for information, HHS seeks comment from interested parties to help shape future policy development and agency action." (U.S. Department of Health and Human Services [HHS])
[Guidance Overview] HHS Publication: 'American Patients First: The Trump Administration Blueprint to Lower Drug Prices and Reduce Out-of-Pocket Costs' (PDF)
44 pages. "HHS has proposed a comprehensive blueprint ... identifying four key strategies for reform: [1] Improved competition; [2] Better negotiation; [3] Incentives for lower list prices; [4] Lowering out-of-pocket costs. HHS's blueprint encompasses two phases: [1] actions the President may direct HHS to take immediately and [2] actions HHS is actively considering, on which feedback is being solicited." (U.S. Department of Health and Human Services [HHS])
'Eliminating the Middlemen': Trump Takes Aim at PBMs in Drug Pricing Speech
"The administration is questioning the current rebate system for PBMs, aiming to restrict its use in the future, and seeking formal input on how to restructure it ... [HHS Secretary Alex Azar] said the administration has 50 relevant policy proposals in the works, though some are being implemented as immediate actions while others are under consideration and headed for a public comment period." (HealthLeaders Media)
Takeaways from Trump's Plans to Lower Drug Prices
"[K]ey proposals unveiled on [May 10:] [1] Lower drug prices for older people ... [2] Persuade other countries to pay more ... [3] Require drug ads to include the price ... [4] Ban 'gag clauses' for pharmacists ... [5] End the patent games." (The New York Times; subscription may be required)
The Role of PBMs in the Rx Drug Supply Chain, and Why It Matters to Employers
"Many PBMs promote the aggressive discounts and Rx drug rebates achieved by their formularies that may look good on paper, but often provide no transparency of true costs. This can result in employers paying much more than they should. When PBMs sell their discounts and rebates to employers, but allow more drugs to flow through the health plan to achieve their desired profit margins, employers end up with higher net costs." (Corporate Synergies)
The Problem with Prescription Drug Prices
"In 2015, two small children of Rockford employees were treated with Acthar, a drug that's been on the market since 1952.... In 2001, Acthar sold for about $40 a vial. Today: more than $40,000. An increase of 100,000 percent.... To keep the price high, the FTC found that [the drug's owner] ... bought another drug that was Acthar's main competitor, a drug called Synacthen ... Synacthen cost $33 in Canada.... Many of the doctors who prescribed a lot of Acthar also were getting money from the company that makes Acthar, for speaking, for consulting, for running research studies for the company, adding up to huge sums.... Express Scripts, the company [Rockford] hired to keep prices down, also had a contract to be the exclusive distributor of Acthar." (CBS News)
Clawbacks: Recent Litigation Targeting Insurers and Pharmacy Benefit Managers
"There have been frequent media reports on the practice of prescription drug clawbacks and federal lawsuits have been filed against insurance companies and PBMs ... The theories of liability being asserted include breach of fiduciary duty under [ERISA], violations of the Racketeer Influenced and Corrupt Organizations Act, as well as under various state laws.... [In one recent case,the ] court found plaintiffs alleged facts sufficient to assert a plausible claim of fiduciary status based on the argument that Cigna's conduct was in violation of plan terms and thus necessarily required the exercise of discretion." [Negron v. Cigna Health and Life Ins. Co., No. 16-1702, consol. with No. 16-1904 (D. Conn. Mar. 12, 2018)] (Proskauer's ERISA Practice Center)
Case Study: The Dangers of Silent Pharmacy Contract Terms (PDF)
"Transparency is critical when it comes to pharmacy contracting. Not only is it important to have robust discount, dispensing fee and rebate guarantees, but the contract terms and definitions must be clear and precise. A high generic discount might not be such a good deal if the contract language isn't strong. Generic drug definitions that lack clarity or are absent from the pharmacy contract altogether can be a costly mistake." (Lockton)
CVS 'Moving Forward' with Aetna Deal, Profit Tops Estimates
"CVS's proposed takeover of Aetna would bring together around 10,000 CVS stores and the health insurer's 22 million customers. A central plank of the deal is transforming the stores into health hubs where consumers can get care, pick up their drugs, buy some cosmetics, and stay out of the hospital." (Bloomberg)
How a Drug Company Under Pressure for High Prices Ratchets Up Political Activity
"As scrutiny rose, Novo Nordisk ... aggressively ratcheted up spending to spread its influence in Washington and to have a louder say in the debates over drug prices.... The pharma industry as a whole has behaved similarly, cranking up political contributions and lobbying.... Pharma businesses overall made political donations of $12.1 million last year, down from a $13.6 million election-year surge in 2016 but 9 percent higher than the haul for 2015 ... Pharma industry lobbying expenses surpassed $171 million last year, the highest level since 2009, during negotiations over the [ACA.]" (Kaiser Health News)
FAQs About Prescription Drug Pricing and Policy (PDF)
38 pages. "This report will address frequently asked questions about government and private-sector policies that affect drug prices and availability. Among the prescription drug topics covered are federally funded research and development, regulation of direct-to-consumer advertising, legal restrictions on reimportation, and federal price negotiation. The report provides a broad overview of the issue s as well as references to more in-depth CRS products. The appendices provide references to relevant congressional hearings and documents and a directory of CRS prescription drug experts." [Report R44832, Apr. 24, 2018] (Congressional Research Service [CRS])
The Impact of Prescription Drug Rebates on Health Plans and Consumers (PDF)
37 pages. "[W]hile PBMs have undoubtedly gained financially from the rebate system, the notion that they divert a large share of rebates to excess prof its is not supported by our analysis. We estimate total PBM profits (excluding mail order) of $11 billion, compared to $89 billion in rebates passed through to payers. Even if half this total profit was 'excess,' such excess would represent a small share of rebates, and eliminating it would reduce premiums by only about 2%." (Altarum)
Rebates, Coupons, PBMs, and the Cost of the Prescription Drug Benefit
"We estimate that total PBM profits in 2016 were about $11 billion or 4.5 percent of PBM revenues (this excludes revenues and profits from PBM-operated mail-order and specialty pharmacies). It is difficult to judge how much of these profits might be deemed 'excessive' due to the inappropriate diversion of rebate dollars to PBM bottom lines. But even if half was found to be excessive, it would amount to less than $6 billion dollars, or roughly 10 percent of total rebates to Medicare Part D and private plans[.]" (Health Affairs)
AHIP Sees SCOTUS Ruling as a Win for Generic Drugs
"A U.S. Supreme Court ruling this week that upholds the constitutionality of a patent review process is being hailed as a win for consumers by the health insurance industry. America's Health Insurance Plans says the high court's 7-2 decision in Oil States Energy Services v. Greene's Energy Group upheld the inter partes review process as a way to prevent drug manufacturers from inappropriately prolonging patent monopolies past the time intended by Congress." (HealthLeaders Media)
Health Plans and Pharmacy Benefit Managers
"Owned jointly by pharmacies and PBMs, SureScripts helpfully relays medication eligibility, patient drug histories, and prescriptions between and among providers, PBMs, and pharmacies. SureScripts earns significant fees for these services, historically from PBMs and pharmacies. But, SureScripts has arguably held back innovative efforts by plans and alternative pharmacy delivery systems to have real time input with providers on prescription decisions. As a result, communications between plans, their contracted PBMs, providers, and pharmacies, though electronic in part, have remained limited." (Sheppard Mullin)
Early Results Show Real-Time Data Nudges Prescribers Toward Cheaper Drugs
"[I]nitial data released by CVS ... shows prescribers that accessed the real-time information switched to a drug covered under the patients plan 85% of the time. Prescribers using the tools switched patients to a lower cost alternative 30% of the time, saving an average of $75 for each prescription." (FierceHealthcare)
CVS Rolls Out New Tool to Combat Rising Drug Prices
"CVS' tool, called the Rx Savings Finder, will enable the company's retail pharmacists to find medicines that are the cheapest option for patients according to the insurance plans they are signed up for. Largest U.S. health insurer UnitedHealth Group last month vowed to pass on pharmacy discounts to customers while filling prescriptions via retail pharmacies and home delivery services." (Reuters)
[Opinion] Pharmacy Associations Urge Senate Judiciary Committee to Hold Hearing on PBMs
"The specific areas of concern the committee was asked to investigate [include]: [1] The lack of oversight of PBMs at the federal and state level. [2] One-sided business arrangements that disadvantage pharmacies in their contracts with PBMs. [3] Spread pricing models ... . [4] Self-dealing ... [5] The inherent conflicts of interests of PBMs owning mail-order pharmacies that directly compete with community pharmacies." (National Community Pharmacists Association [NCPA])
Why Health Insurers and PBMs Are Merging
"[1] The desire to keep costs down is a major factor pushing companies to combine forces, but it may not be a good enough reason on its own to justify certain of these vertical mergers ... [2] Insurers may also look to PBMs as an attractive way to diversify their business and gain access to additional perhaps less-restricted revenue streams ... [3] The PBM model has been under pressure from increasing demands for more transparency about business practices such as drug manufacturer rebates and volume discounts." (HealthLeaders Media)
How the Opioid Crisis Has Affected People with Employer Coverage
"[O]pioid prescription use and spending among people with large employer coverage increased for several years before reaching a peak in 2009. Since then, use of and spending on prescription opioids in this population has tapered off and is at even lower levels than it had been more than a decade ago.... Meanwhile, though, the cost of treating opioid addiction and overdose ... among people with large employer coverage has increased sharply, rising to $2.6 billion in 2016 from $0.3 billion 12 years earlier, a more than nine-fold increase." (The Peterson-Kaiser Health System Tracker)
[Guidance Overview] Ohio Requiring Prescription Drug Transparency for Consumers
"[Bulletin 2018-02] requires insurers and pharmacy benefit managers (PBMs) to remove the 'gag order' that prevents disclosing to consumers the most affordable prescription drug option available to them. Currently, some insurers and PBMs use contractual provisions to prevent pharmacists from discussing with consumers if other options are available to purchase their prescriptions at a lower cost. This bulletin would prohibit that practice." (Ohio Department of Insurance)
Clinical Reviews of Pharmacy Meds Can Help Reign in Cost
"Clinician-consultants will review overall pharmacy benefits claims filed and utilization to see which drugs are being filled -- and, importantly, what is being filled unnecessarily. During clinical reviews, consultants will look for certain high-cost specialty drugs or brand-name drugs prescribed when there is a much lower-cost alternative, and flag them. Then, they'll present the drug list to the employer and discuss the pros and cons of changing the Rx formulary to save money." (Corporate Synergies)
CMS Lowers the Cost of Prescription Drugs for Medicare Beneficiaries
"[A]ctions that CMS is finalizing to lower the cost of prescription drugs include: [1] Allowing for certain low-cost generic drugs to be substituted onto plan formularies at any point during the year ... [2] Increasing competition among plans by removing the requirement that certain Part D plans have to 'meaningfully differ' from each other ... [3] Increasing competition among pharmacies by clarifying the 'any willing provider' requirement[.]" (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
Aetna Will Pass Along Discounts as Drug Price Scrutiny Increases
"Aetna Inc. will pass on the discounts it negotiates on prescription drugs to about 3 million of its members ... The discounts, which can amount to more than half a drug's list price, will be passed on at the pharmacy counter for many people starting next year ... The move by the No. 3 U.S. health insurer follows a similar decision earlier this month by its larger peer, UnitedHealth Group Inc." (Bloomberg)
[Opinion] The Real Problem Behind High-Priced Drugs Starts at the Beginning
"The original list price of a drug drives the entire pricing process, and that price is determined and controlled 100 percent by the drug company.... [W]hen competition increases because new generic drugs are approved, drug prices tend to go ... down.... Big Pharma is the only stakeholder group to oppose enacting bipartisan legislation -- the CREATES Act -- that would ... limit access to adequate samples of branded products so generic companies cannot do the testing required to bring new lower-priced generics to market." (America's Health Insurance Plans [AHIP])
Cigna-Express Scripts Deal Poses Challenges to Insurers
"If Cigna Corp. completes its acquisition of Express Scripts Holding Co., the PBM's health insurer clients will have to decide whether to keep working with an entity now owned by a fellow payer.... Express Scripts currently has 51 health plan clients ... Ten of those are Blue Cross Blue Shield-affiliated plans, which could opt to go with Anthem's in-house PBM -- IngenioRx -- once it debuts in 2020." (AISHealth)
[Opinion] Myth: Drug Prices Accurately Reflect Their Costs for Development
"[T]he assumption that drug prices accurately represent their cost is not completely plausible.... [T]he industry sets its prices on its own terms because it can. Patent laws, data exclusivity and its fiercely competitive and fast-consolidating marketplace lend to transparency avoidance. Drug manufacturers, their distributors and pharmacy benefits managers operate in virtual obscurity, protecting their intellectual properties, business processes and costs of operating from public scrutiny." (Paul Keckley)
Arkansas House and Senate Approve Regulation of PBMs
"The bill would allow state regulators to supervise PBMs' networks to ensure that they provide convenient patient access to pharmacies and a fair and sustainable reimbursement rate for pharmacist services." (AISHealth)
Policy Strategies for Aligning Price and Value for Brand-Name Pharmaceuticals
"To achieve the difficult balance between necessary incentives for innovation and affordability, many economists favor 'value-based' pricing, in which the price for a new drug reflects an assessment of the comparative effectiveness of the drug compared to other available treatments. [This brief explores] the different varieties of value-based pricing, and [outlines] several measures through which drug competition may be increased, supported by regulatory steps and payment mechanisms to bring drug prices into greater alignment with their underlying clinical value." (Health Affairs)
Promoting Competition to Address Pharmaceutical Prices
"This brief surveys the two principal types of pharmaceutical competition -- inter-brand and brand/generic -- and examines the reasons they may fail to produce lower prices for patients ... The brief then reviews the policy interventions that could help address these shortcomings. Such proposals include increasing the efficiency of generic drug approval, allowing temporary importation of drugs during domestic shortages or price fluctuations, and discouraging the improper use of patent exclusivities." (Health Affairs)
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