Drug Coverage

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.

Over the last five years, both PBMs and drug manufacturers have implemented restrictions that put more of the costs for specialty medications on patients.

The study found that Medicare patients used low-benefit options more frequently than high-benefit options.

HyQvia is the first FDA-approved treatment for primary immunodeficiency (PI) available as a once-a-month subcutaneous injection. Other treatments for PI, while similarly effective, present a greater burden to patients, often requiring more frequent injections or more invasive routes of administration

Tirzepatide was associated with a greater reduction in hemoglobin A1c and body weight versus semaglutide. Though, with a current list price of $1,023 for a one-month supply of tirzepatide (Mounjaro; Lilly), is it worth it?

The combination of Padcev with Merck’s Keytruda has a potentially large market: approximately 8,000 to 9,000 U.S. patients would be eligible for this combination in the U.S.

The new feature automatically applies manufacturer-sponsored coupons directly to an eligible patient’s order. So far, just a few pharma companies have made their coupons available through Amazon.

Members of the Senate Finance Committee want to modernize the rules around PBM business practices to lower out-of-pocket costs and increase competition.

The suit alleges that Express Scripts, Prime and Prime customer Humana Pharmacy Solutions are able to share drug pricing and rebate information to increase prices for insulins, biologics and cancer drugs.

Out-of-pockets costs were higher among those using branded or more recently launched drugs.

RxBenefits helps patients in self-funded plans find and apply for alternative sources of funding for specialty medicines and facilitates enrollment.

The proposed legislation, sponsored by Sens. Chuck Grassley and Maria Cantwell, aims to increase transparency of PBM business practices.

The company also will establish a $35 cap on out-of-pocket costs for Lantus for all patients with commercial insurance.