The debate on whether the Big 3 Pharmacy Benefit Managers (PBMs) offer better price savings just because of their size is a myth. The notion is largely perpetuated by the old guard who has benefited from overpayments received from opaque PBM business practices. However, the truth is that the Big 3 have more purchasing power, but their clients often don’t realize the full benefit. Does size really matter when it comes to pharmacy benefit managers and cost savings?

PBMs generate revenue from rebates following each eligible drug claim. Therefore, a PBM’s interest typically rests in raising prescription drug prices rather than decreasing them to get larger rebates. Pharmaceutical firms’ priorities have been fundamentally altered by this method; rather than competing to provide patients with high-quality, reasonably priced medications, they are now more interested in gaining the PBMs’ support for the top spot on formularies by providing generous incentives thus driving up costs.

Furthermore, there is a high concentration of purchasing power due to the vertical integration of the major PBMs, specialty pharmacies, and insurers. As a result, the three largest PBMs control 80% of the market for prescription volume. The following diagram shows the vertical business connections between retail chains, PBMs, and insurers:

For instance, while a rebate aggregator may pay a $3000 rebate for drug “A” and return every penny back to the client with an audit trail, the Big 3 may earn $4000 on the same drug but retain $1200 in-house, resulting in the plan sponsor pocketing an additional $200 when working with a radically transparent, albeit smaller, PBM.

Additionally, non-fiduciary PBMs use estimates in their price quotes, which can lead to discrepancies between projected and actual costs. As a result, the plan sponsor’s PBM contract is the most valuable tool to address the actual level of drug spending, not cost projections. However, non-fiduciary PBMs often use opaque contract language to eat away at the proposed savings, such as discount and rebate guarantees as soon as your plan goes live.

It’s essential to consider the PBM management fee in how you procure pharmacy benefit management services. The PBM management fee is largely an undisclosed fee that non-fiduciary PBMs charge for providing their services to plan sponsors, and the bulk of this fee is buried in the final plan pharmacy cost. Therefore, the contract is king.

Check out this free webinar if you’ve never considered the PBM management fee in PBM procurement. With transparency in PBM practices, smaller PBMs can offer more significant cost savings, as illustrated in the webinar below:

Remember that the size of a PBM does not always guarantee better price savings. Look for transparency in PBM practices to ensure that you’re getting the most value out of your pharmacy benefit management services. Having a trained eye enables a person to quickly and accurately identify details, patterns, and anomalies that may not be immediately apparent to an untrained observer. This can lead to better decision-making, problem-solving, and overall performance in managing a pharmacy benefit. The Certified Pharmacy Benefits Specialist (CPBS) program is the #1 training option for employee benefit brokers, consultants, HR, and Finance.

2023 Trends in Specialty Drug Benefits Report Released by PSG and other notes from around the interweb:

• 2023 Trends in Specialty Drug Benefits Report. Specialty drug costs have continued to push the boundaries in terms of complexity and affordability. The complicated landscape must consider many variables, such as multiple dispensing channels, dual payment methods, and site of care. This report takes a detailed look into what plan sponsors are facing as they make decisions relative to specialty drug benefit plan design. Additional topics covered in the report include increasing usage of new-to-market formulary blocks, interest in site of care programs, prior authorization tracking and reporting, and use of strategies related to biosimilars.

• Expert: Targeted Approach of Specialty Drugs Drives Rising Prices. In an interview with Pharmacy Times at the 2023 Asembia Specialty Pharmacy Summit, Naveen Mansukhani, BPharm, director of Operations and Account Management for Retail Pharmacy Services at Cardinal Health, discussed skyrocketing prices for specialty drugs and what is driving those increases. Q: Despite being just about 2% of overall prescription volume, specialty medications are now more than half of total annual pharmacy spending. Are there specific drug classes or disease states that are driving this issue? Naveen Mansukhani, BPharm: Specialty drugs are very targeted drugs to targeted disease states. Inflammatory disorders, oncology, multiple sclerosis, those are just some of the drug classes that are currently driving the specialty spend.

• Data and Collaboration Provide a Way Forward for Value-Based Care. In the 13 years since the passage of the Affordable Care Act, healthcare organizations and other stakeholders have recognized that tracking key performance indicators such as readmission rates, average length of stay and patient satisfaction are insufficient to realize the full potential of a patient-centered care experience. As value-based care models mature, measurements have expanded to include the social determinants of health and other issues that providers and payers must consider if they are to treat patients holistically. This includes the availability of transportation, family assistive services, affordable housing and other factors that provide a foundation for population health. This progress is encouraging, but the industry still has a long way to go. Clinical and financial metrics are just one lens to assess the success in delivering value-based care, and even medical, demographic, and economic data is insufficient. More granular, incisive data on the healthcare industry itself is required to fully assess how much progress the industry is making in delivering value-based care.

• What is transparency? Six things to look for in a PBM contract. If you don’t know the answer, they’re not transparent. PBMs aren’t incentivized to be transparent because they make money on drugs in many creative ways. So long as this remains true, their interests are not aligned with those of the employer or employees, and being transparent puts their business model at risk. For example, it’s an open secret that many PBMs make huge profits by negotiating “rebates” with drug manufacturers in the name of lowering the price of drugs. The truth is that those PBMs run a pay-to-play scheme, excluding from their formularies the drug manufacturers that don’t pay the rebates. The PBMs argue they are now passing most rebates received to employers to reduce drug costs. It should be no surprise that, at the same time rebate revenue has gone down for PBMs, they experienced a commensurate or greater increase in “admin fees” received from manufacturers for “processing rebates.” Whether you call it a rebate or an admin fee, it has the same effect: driving up wholesale drug prices and lining the PBM’s pocket at employer and patient expense. Another customary practice is “spread pricing,” where a PBM adds margin to the price they pay the pharmacy versus what they charge health plans and patients. Who keeps the spread? The PBMs, of course. And pharmacy owners, health plans, and health care consumers pay the price.

The current pharmacy benefit management industry developed from transparent third-party prescription claims adjudication in less than two decades to become incredibly lucrative and opaque. Most value choices that plan sponsors cannot or do not want to make are made by PBMs. Self-insured employer strategies for optimizing pharmacy benefit plan design includes six critical pillars. However, the majority of PBMs are non-fiduciary, which implies that their interests are not congruent with those of their customers. Without this, there wouldn’t be an issue.

Even worse, non-fiduciary PBMs take advantage of the inexperienced plan sponsors’ purchasing power by haggling with drug companies and pharmacies for their own financial gain. Prior to realizing they might utilize the inexperienced consumers’ purchasing power for their own financial advantage, non-fiduciary PBMs concentrated on cost-efficiency, or achieving the greatest results at the lowest possible price. In many instances, the emphasis has turned to promoting the services that would bring in the greatest money for the PBM.

Fiduciary PBMs are required to act in their clients best interest. Bad actors use pharmacy benefit plan design for bad things. Hence, smart purchasers of PBM services want more control over their plan design not less. If this is you, here are self-insured employer strategies for optimizing pharmacy benefit plan design that will lower your pharmacy benefit costs and improve outcomes.

I. Evaluate your internal resources and pharmacy expertise

If you’re reading this and work for a self-funded employer never retain the services of a PBM or a PBM consultant who benefits when your pharmacy costs increase. Should you do so, never leave them completely to their own accord.

• Do you have the expertise within your company to design the pharmacy benefit plan? Or do you need pharmacy benefits education or the services of a pharmacy benefits consultant?
• How do you want to be involved in the management of the plan design after it is set up?
• Do you have the expertise and resources to manage the plan design or do you need to build in the incentives for the PBM to manage your program? In other words, hire consultants not because you lack the requisite knowledge to design or manage the pharmacy benefit plan in-house, but because you lack the time or human capital to go it alone. Plan sponsors might be surprised to learn that many so called advisers know little more than they do when it comes to pharmacy benefits. 
• Who is watching the watcher? Employ digital innovations to continuously monitor your PBMs performance.

II. Access

A formulary is a list of medications for which a plan will provide reimbursement. When considering a formulary, access defines the basic aspects of a pharmacy benefit design which includes but is not limited to:

• The products that will be covered
• The products that will not be covered
• The products that need prior approval
• Plan cap or maximum dollar amount a plan will pay for outpatient drug benefits
• Mail service benefits including specialty pharmacy, if any
• Pharmacy network makeup 

Managing a formulary and improving its efficiency involves an ongoing assessment of the drugs on the formulary as well as any new potential drug therapy treatments. Again, do not leave this responsibility solely in the hands of the PBM unless it has agreed to accept fiduciary responsibility. Lastly, plan design considerations must take into account DAW or dispense as written laws for each state.

III. Medication Adherence

Medication adherence is a large and growing issue that has an impact not only on patients’ health, but also on employer finances. Non-adherence to medications has been linked to 30-50% of treatment failures and 125,000 deaths each year, according to statistics gathered by the American College of Preventive Medicine. In addition, non-adherence results in $290 billion in annual healthcare spending, $100 billion of which is due to hospitalization and rehospitalization that could have been avoided if medications were taken as prescribed. Simply put, even the most perfectly designed plan in the world can’t make up for poor adherence. Monitor adherence plan-wide and take corrective action for patients whose adherence is average or worse.

IV. Cost-Containment

Major cost-containment elements of pharmacy benefit plan design are plan restrictions, limitations and exclusions. There are many types of limitations used in varying degrees but they often lack the oversight [human] necessary to be effective over the long-haul. These elements encourage members to utilize low(er) cost alternatives:

• Therapeutic Substitution
• Mandatory Generic
• Plans caps or the maximum amount a plan will pay for outpatient drug benefits
• Partial fill programs or quantity limits on medication members can receive

Cost-Shifting (or Cost Sharing)

There are three major types of cost-sharing: copayments, deductibles and coinsurance. Cost shifting refers to when members receive a more costly alternative to a preferred product they are required to pay the higher copayment. Another example, when members receive a branded product which has an available generic equivalent, they are required to pay the additional costs associated with the branded. Cost-shifting does not mean placing an unnecessary financial burden (i.e. copay accumulators) on patients. According to the economic principles of demand, as price increases, demand tends to decrease. In the case of prescription drugs, price is the member’s OOP (out-of-pocket). As cost sharing increases, utilization decreases. However, it’s a catch twenty-two as there is a point of diminishing returns. You don’t want utilization to decrease so much that it causes an increase in hospitalizations or emergency room visits, for example.

VI. Outcomes and Safety

The sixth and final pillar does not provide or limits coverage for those products that do not improve or maintain the health of the members or have a tendency to be abused or overused. These products are often referred to as LCVs or low clinical value drugs. Some examples include:

• Hair growth treatments
• Over-the-counter drugs
• Growth hormones
• Erectile dysfunction
• Weight loss/gain drugs
• Smoking cessation products.
• Opioids 

This portion of the pharmacy benefit design is accomplished by clearly defining which drugs and/or therapeutic categories will not be covered or are limited in their coverage. Once a plan is in place there must be ongoing evaluation (far beyond standard reports) to determine how well the plan is achieving the goals and objectives upon which the plan is based. Critical to the process is the availability of data. I’m aware how tough some PBMs make it to get access to data. You would be wise to negotiate unrestricted access to this data upfront; before the contract is signed.

In conclusion, there are four primary drivers of pharmacy cost; price, product mix, utilization, and cost share. Pharmacy benefit plan design is responsible for three-fourths of the cost drivers which means it has a substantial impact on outcomes and final cost to the plan.

Study Reveals Factors That Dissuade Commercial Plans From Covering Biosimilars and other notes from around the interweb:

• Study Reveals Factors That Dissuade Commercial Plans From Covering Biosimilars. A recent study found factors that influence a commercial plan’s likelihood of placing coverage restrictions on biosimilars, including how many competitors are on the market, the prevalence of the drug indications, and the plan’s relationship with pharmacy benefit managers (PBMs). The study, published in BioDrugs, is the first to examine the characteristics associated with US commercial health plan biosimilar coverage. It also expanded on previous literature that found that biosimilars were preferred over their reference products in only 14% of coverage decisions and were less preferred in 33% of cases. The researchers used data on coverage decisions from the Tufts Medical Center Specialty Drug Evidence and Coverage database, cost-effectiveness evidence from the Tufts Medical Center Cost-Effectiveness Analysis Registry, and list prices from the Merative Micromedex RED BOOK. They identified 1181 coverage decisions through August 2021 regarding 19 commercially available biosimilars for 7 reference products and 28 indications.

• AHF Confronts Cigna CEO over PBM’s ‘Rapacious’ Greed. AIDS Healthcare Foundation (AHF), the world’s largest HIV/AIDS healthcare provider, sharply criticized health care behemoth Cigna today over its management of Express Scripts, the nation’s second largest Pharmacy Benefit Manager (PBM), which Cigna acquired in a 2018 merger. AHF’s criticism comes on the heels of a so-called “transparency” campaign Cigna and Express Scripts recently launched. In a letter to Cigna CEO David Cordani, AHF President Michael Weinstein details how Cigna, through its Express Scripts PBM, “…is ripping apart the healthcare system through its rapacious, self-serving, member-unfriendly practices…” Issues concerning AHF and hundreds of independent and mom-and-pop pharmacies nationwide include the following: Express Scripts (ESI) actively drives pharmacies out of its networks through reimbursements that don’t even cover a pharmacy’s drug costs, let alone the costs associated with dispensing the drugs and consulting with patients. This predatory practice is contributing to the bankruptcy of independent pharmacies and to the creation of pharmacy deserts, leaving members stranded.

• Florida is still battling the federal government over imported drugs. Gov. Ron DeSantis and then-Florida House Speaker Jose Oliva, R-Miami Lakes, made the drug-importation issue a priority in 2019, with lawmakers approving a plan to make imported drugs available in government programs such as Medicaid, the prison system and facilities run by the Department of Children and Families. At least initially, the state wants to import drugs to treat conditions such as HIV and AIDS, hepatitis C, diabetes, and mental illness, according to court documents. The state submitted a proposal in November 2020 to the Food and Drug Administration, which would need to approve the importation program. The proposal falls under what is known as the federal Section 804 Importation Program, or SIP

• What is transparency? Six things to look for in a PBM contract. If you don’t know the answer, they’re not transparent. PBMs aren’t incentivized to be transparent because they make money on drugs in many creative ways. So long as this remains true, their interests are not aligned with those of the employer or employees, and being transparent puts their business model at risk. For example, it’s an open secret that many PBMs make huge profits by negotiating “rebates” with drug manufacturers in the name of lowering the price of drugs. The truth is that those PBMs run a pay-to-play scheme, excluding from their formularies the drug manufacturers that don’t pay the rebates. The PBMs argue they are now passing most rebates received to employers to reduce drug costs. It should be no surprise that, at the same time rebate revenue has gone down for PBMs, they experienced a commensurate or greater increase in “admin fees” received from manufacturers for “processing rebates.” Whether you call it a rebate or an admin fee, it has the same effect: driving up wholesale drug prices and lining the PBM’s pocket at employer and patient expense. Another customary practice is “spread pricing,” where a PBM adds margin to the price they pay the pharmacy versus what they charge health plans and patients. Who keeps the spread? The PBMs, of course. And pharmacy owners, health plans, and health care consumers pay the price.

Choosing a fiduciary PBM could revolutionize your healthcare benefits. Importantly, ERISA now codifies key elements that must exist for a PBM-Plan arrangement to be judged reasonable, expanding on the reasonableness standard. For instance, a PBM-Plan contract cannot be deemed reasonable unless the PBM makes the following written disclosures:

• A description of the services that will be rendered to the Plan in accordance with the agreement;
• A declaration that the PBM, an affiliate, or a subcontractor will, or reasonably anticipates providing, services in accordance with the agreement directly to the Plan in its capacity as fiduciary;
• A breakdown of each direct payment that the PBM, an affiliate, or subcontractor anticipates receiving in relation to the services rendered, whether in total or by service;
• A description of all indirect payments that the payer expects to make to the PBM, an affiliate, or a subcontractor in connection with the services mentioned; this description should also include information about the contract between the payer and the relevant PBM, affiliate, or subcontractor that governs the payment of indirect payments;
• If compensation is determined based on transactions (such as commissions, finder fees, or other similar incentive compensation based on business placed or retained), a description of any compensation that will be paid among the PBM, an affiliate, or a subcontractor in connection with the services, including identification of the services for which such compensation will be paid and identification of the payers and recipients of such compensation (including the status of the pay)
• An explanation of any remuneration that the PBM, an affiliate, or a subcontractor could be expecting to get in connection with the contract or arrangement’s termination, as well as how any pre-paid money will be computed and reimbursed after that [1].

Watch the on-demand webinar below to learn how choosing a Fiduciary PBM could revolutionize your healthcare benefits. If you are short on time, increase the playback speed to 1.25x or 1.5x.

Additionally, PBMs are obligated by ERISA to provide any additional information on compensation received by the PBM in connection with the contract that is necessary for the Plan to meet its reporting obligations under the CAA. This information must be provided upon written request from the Plan [2]. Click here to learn more about TransparentRx, America’s first fiduciary model PBM.

[1] See 29 U.S.C. § 1108(b)(2)(B)(i) and (iii).

[2] See 29 U.S.C. § 1108(b)(2)(B)(vi).

3 Digital Health Strategies to Improve Health Plan Member Experience and other notes from around the interweb:

• 3 Digital Health Strategies to Improve Health Plan Member Experience. Health plans have innumerable reasons to focus on improving member experience right now. The Centers for Medicare and Medicaid Services (CMS) are heavily weighting member experience in STARS ratings and HEDIS scores. And healthcare consumers want more accessible care and support. Digital member engagement tools give health plans the opportunity to deliver a better member experience by making healthcare more convenient—which, in turn, drives satisfaction and retention. Members are also looking to get the best value for the soaring prices they’re paying for health insurance coverage. But adopting a new digital health solution can be challenging, especially when it comes to aligning goals with staff and member expectations. Building a digital engagement strategy requires buy-in from individuals across an organization. Here, we’re highlighting three strategies health plans can use to improve digital adoption and enhance the member experience.

• 15 biggest pharmacies by prescription revenue. Pharmacies earned a record $548 billion from prescription dispensing revenues in 2022, and 15 pharmacies account for 75 percent of that figure, according to Drug Channels. The market share from the top fifteen dipped from 2020 to 2021 and again from 2021 to 2022, according to past reports. They accounted for 78.6 percent of the market in 2020, 76.9 percent in 2021 and 75.6 percent in 2022, according to the site’s past reports. The decrease from 2021 to 2022 is because of Walgreens’ losses after the Prime Therapeutics deal, the report said. Five of the largest pharmaceutical companies are owned by companies that also have a pharmacy benefit manager, including CVS with Caremark, Cigna with Express Scripts, Centene with Envolve Health, Humana with CenterWell and UnitedHealth Group with Optum. Click here to see the Top 15 ranked by prescription revenue.

• Survey: More than Half of Payers Use Outcomes-based Contracts. About 58% of payers had at least one outcomes-based contract with a pharmacy benefit manager for prescription drugs in 2022, according to a survey published last week. In an outcomes-based contract, prescription drug reimbursement is based on the outcomes achieved for the patient. These contracts represent a shift to value-based care. Avalere Health, a healthcare business consulting firm, published the survey. The company conducted it online from February 14 to February 20 and received responses from forty-six health plans. This is the fifth year the company has conducted the survey. Of the payers that had at least one outcomes-based contract, more than 35% had more than ten outcomes-based contracts in 2022. Another 10% of payers had five to ten contracts, and a little over 10% had two to five contracts. About 15% had no contracts but were in negotiations for one or more. Less than 10% had no contracts and were not planning to take any on. In addition, the survey found that of the respondents who had at least one outcomes-based contract in 2022, the top therapeutic areas the contracts were used for were oncology, cardiology, endocrinology. The therapeutic areas with the lowest number of outcomes-based contracts were infectious disease, pulmonology, and rheumatology.

• What is transparency? Six things to look for in a PBM contract. If you don’t know the answer, they’re not transparent. PBMs aren’t incentivized to be transparent because they make money on drugs in many creative ways. So long as this remains true, their interests are not aligned with those of the employer or employees, and being transparent puts their business model at risk. For example, it’s an open secret that many PBMs make huge profits by negotiating “rebates” with drug manufacturers in the name of lowering the price of drugs. The truth is that those PBMs run a pay-to-play scheme, excluding from their formularies the drug manufacturers that don’t pay the rebates. The PBMs argue they are now passing most rebates received to employers to reduce drug costs. It should be no surprise that, at the same time rebate revenue has gone down for PBMs, they experienced a commensurate or greater increase in “admin fees” received from manufacturers for “processing rebates.” Whether you call it a rebate or an admin fee, it has the same effect: driving up wholesale drug prices and lining the PBM’s pocket at employer and patient expense. Another customary practice is “spread pricing,” where a PBM adds margin to the price they pay the pharmacy versus what they charge health plans and patients. Who keeps the spread? The PBMs, of course. And pharmacy owners, health plans, and health care consumers pay the price.

Medication therapy management (MTM) is a patient-centered service provided by healthcare professionals such as pharmacists, doctors, or nurses. MTM aims to optimize medication therapy for patients with chronic health conditions who take multiple medications. MTM involves a comprehensive review of a patient’s medication regimen to identify and resolve medication-related problems. It also includes education and counseling to help patients manage their medications and improve their health outcomes. Incorporating medication therapy management into self-insured employer health programs is a win-win.

The benefits of MTM are numerous. By optimizing medication therapy, MTM can help patients achieve better health outcomes, reduce medication-related problems, and lower healthcare costs by preventing hospitalizations and emergency room visits. Additionally, MTM can improve patient satisfaction and adherence to medication therapy. MTM services can also help healthcare providers identify and manage medication-related issues that might otherwise go unnoticed, such as drug interactions, medication side effects, or non-adherence to medication regimens.

Consider an MTM program as a tool for self-insured employers to assess the efficiency of the funds they set aside to pay for the health care of their employees and dependents. Incorporating MTM into their employee health programs can be a smart investment with an expected ROI of 2x. The ROI MTM services can help reduce healthcare costs by optimizing medication therapy and preventing costly medical interventions. Additionally, by providing MTM services, self-insured employers can show that they care about their staff’s health by raising morale and productivity.

However, there are also challenges associated with MTM that self-insured employers should be aware of. One of the primary challenges is the cost ($.50 – $2.00 PMPM) of providing MTM services. MTM services may require additional staffing, training, and technology investments, which can be a barrier for some healthcare providers and employers. Additionally, there may be resistance from some patients who are not accustomed to working with pharmacists or other healthcare providers to manage their medication therapy.

To successfully incorporate MTM into employee health programs, self-insured employers should consider the following recommendations:

1. Start small: Begin by targeting a specific patient population or health condition and gradually expand the MTM program as resources and demand allow.
2. Identify key partners: Collaborate with healthcare providers, such as pharmacists, doctors, and nurses, to provide MTM services to employees.
3. Communicate the value of MTM: Educate employees on the benefits of MTM services and how they can help improve their health outcomes.
4. Measure outcomes: Track key metrics, such as healthcare costs, hospitalizations, and medication adherence, to evaluate the effectiveness of MTM services and identify areas for improvement.

In summary, MTM is a patient-centered service that can help optimize medication therapy and improve patient outcomes when incorporating medication therapy management into self-insured employer health programs. For self-insured employers, incorporating MTM into employee health programs can lead to improved health outcomes, reduced healthcare costs, and improved employee satisfaction and productivity. However, to successfully incorporate MTM into employee health programs, self-insured employers must carefully consider the costs, benefits, and challenges associated with this service and develop a strategic plan for implementation.

Biosimilars Are Mighty, Can Help Alleviate Drug Spend Cost Burden and other notes from around the interweb:

• Ohio attorney general sues pharmacy benefit managers, calling them gangsters. Calling them “modern gangsters,” Ohio Attorney General Dave Yost on Monday accused pharmacy benefit managers of illegally driving up drug prices for patients who rely on insulin and other key medications. “Medications shouldn’t cost an arm and a leg, metaphorically or literally,” Yost said in a written statement. “Insulin is just a symptom of the problem; PBMs are the disease.” Yost filed a lawsuit in Delaware County Common Pleas Court against Express Scripts, Prime Therapeutics, Ascent, Humana Pharmacy Solutions and two parent companies. He alleges the companies colluded to control drug prices and have failed to live up to promises to negotiate lower drug prices from manufacturers and deliver those savings to patients. Instead, Express Scripts created a complex ‘pay to play’ rebate scheme that pushes manufacturers to boost drug prices to get their medications on preferred lists.

• Pharmacy Benefit Manager Transparency Act Passes in Senate Committee Vote. On March 22, 2023, the Senate Committee on Commerce, Science and Transportation voted 18-9 to approve sending the bipartisan Pharmacy Benefit Manager (PBM) Transparency Act to the full Senate. The bill introduced by Democrat Commerce Committee Chair Senator Maria Cantwell of Washington and Republican Budget Committee Ranking Member Senator Chuck Grassley of Iowa in January 2023 aims to make prescription drug pricing more transparent. The Congressional Budget Office’s preliminary estimates suggest that the PBM Transparency Act would save $740 million to taxpayers over the next 10 years. The legislation arises out of substantial concerns about the anti-competitive and predatory tactics that PBMs have engaged in throughout the past decade to erode the prevalence of independent pharmacies across the country.

• Biosimilars Are Mighty, Can Help Alleviate Drug Spend Cost Burden. Biosimilar availability also lends itself to more opportunities for substitution at the pharmacy level, like how generic products are substituted for brand name medications. However, for one biosimilar to be substituted for another without requiring physician permission, it must have an interchangeability designation from the FDA. To obtain interchangeability, most products, excluding insulins and ophthalmology products, companies are required to conduct additional clinical trials—after which pharmacists can automatically substitute them for the reference product, provided state laws allow it. Biosimilars alone are projected to have global savings of up to $150 billion by 2027.7 So, why is there still a holdup to their wider implementation?

• Claims Cost Transparency: Using Data to Optimize Medical Benefits Costs. Employee benefits are the second largest budget item in employee compensation, with medical benefits consuming the bulk of that cost. Yet, companies with fully insured medical plans often have limited financial transparency and control when it comes to managing these costs. Try viewing the actual, full cost for a broken ankle, and you’ll see that pricing is not so transparent. Companies that know and understand their medical & Rx claims can make decisions that will improve plan utilization and reduce overall costs. Claims cost analysis allows you to drill down into the data and see what you need in your health plan to boost utilization and get your employees and their families better care. Many small and mid-size companies have fully insured plans, allowing for a fixed monthly cost. The carrier creates a pool, lumping your company with others. The carrier may determine your rate based on costs for the entire pool, meaning you’ll pay a set cost whether your company’s claims are higher or lower than average. When it comes to data, however, fully insured plans may not provide transparency or flexibility. They offer some claims data, but the carrier owns all of it, including your high claimant utilization.

Pharmacogenomics is a field of study that examines how a person’s genetic makeup affects their response to medication. It involves the use of genomic information to optimize drug therapy for an individual based on their unique genetic profile. Benefit consultants and brokers must recognize how pharmacogenomics benefits self-insured employers then incorporate these programs into the pharmacy benefit cost management process.

The benefits of pharmacogenomics are numerous. By using genomic information to tailor drug therapy to an individual’s unique genetic makeup, healthcare providers can optimize medication effectiveness while minimizing potential side effects. This approach can lead to better patient outcomes, reduced healthcare costs, and improved quality of life for patients. Keep in mind these tests aren’t akin to 23andme where everyone is eligible. PGx is limited to specific genes for which testing is available.

Pharmacogenomics (PGx) testing is a type of genetic testing that examines specific genes involved in drug metabolism and response. The test analyzes variations or mutations in these genes that may affect how an individual’s body processes medications. The testing process typically involves a simple blood or saliva sample from the patient, which is sent to a laboratory for analysis. The laboratory then examines specific genes associated with drug metabolism and response, such as those involved in drug transport, metabolism, or receptor binding.

Based on the results of the test, healthcare providers can determine how a patient’s genetic makeup may impact their response to certain medications. This information can be used to adjust the dosage or select an alternative medication that is more likely to be effective or have fewer side effects based on the patient’s genetic profile. In short, PGx testing eliminates wasteful spending and improves patient outcomes.

It’s important to note that pharmacogenomics testing is not appropriate for all patients or medications, and the results of the test must be interpreted in conjunction with a patient’s medical history and other relevant factors. Additionally, not all insurance plans cover the cost of pharmacogenomics testing, which can be a barrier for some patients. Nonetheless, pharmacogenomics testing is a promising tool that can help healthcare providers personalize drug therapy and improve patient outcomes.

For self-insured employers, pharmacogenomics can be particularly beneficial. By incorporating pharmacogenomics into their employee health programs, self-insured employers can reduce healthcare costs and improve productivity by optimizing drug therapy for their employees. Additionally, by providing personalized medication recommendations based on an individual’s genetic profile, self-insured employers can demonstrate their commitment to employee wellness and enhance their reputation as a progressive employer.

However, there are also challenges associated with pharmacogenomics. One of the primary challenges is the cost of genetic testing, which can be a significant barrier for some patients and employers. Additionally, there are concerns around privacy and the ethical implications of using genetic information to make medical decisions. Finally, there is a need for more research to determine the effectiveness of pharmacogenomics in various clinical settings and patient populations.

In summary, pharmacogenomics has the potential to revolutionize drug therapy by tailoring medication recommendations to an individual’s genetic profile. Optimizing medication therapy is critical to managing drug costs. Benefit consultants must recognize how pharmacogenomics (PGx) benefits self-insured employers. For self-insured employers, the right PGx program can lead to improved employee health outcomes and reduced healthcare costs. However, there are also challenges associated with pharmacogenomics that must be carefully considered and addressed.

Ohio attorney general sues pharmacy benefit managers, calling them ‘gangsters,’ and other notes from around the interweb:

• Ohio attorney general sues pharmacy benefit managers, calling them ‘gangsters’. The music has stopped. Calling them “modern gangsters,” Ohio Attorney General Dave Yost on Monday accused pharmacy benefit managers of illegally driving up drug prices for patients who rely on insulin and other key medications. “Medications shouldn’t cost an arm and a leg, metaphorically or literally,” Yost said in a written statement. “Insulin is just a symptom of the problem; PBMs are the disease.” Yost filed a lawsuit in Delaware County Common Pleas Court against Express Scripts, Prime Therapeutics, Ascent, Humana Pharmacy Solutions and two parent companies. He alleges the companies colluded to control drug prices and have failed to live up to promises to negotiate lower drug prices from manufacturers and deliver those savings to patients. Instead, Express Scripts created a complex ‘pay to play’ rebate scheme that pushes manufacturers to boost drug prices to get their medications on preferred lists.

• The CAA will ensure that doing the right thing is the only option. The CAA will soon begin holding employers accountable for upholding their fiduciary responsibility and exploring insurance options that lower the cost of employee health care. Word is circulating that the CAA may allow employees to sue employers if they don’t effectively manage their health care benefits. Even though the idea of employees taking legal action against their employers regarding health care benefits sounds terrible, if this interpretation is correct, it should have a positive effect on the health care industry. Should employers be worried about this new eventuality? No, not all of them. Most employers want to help their people — they just don’t fully understand that they have options. The new CAA guidelines will push employers and their brokers to explore other avenues that lower health care costs. It is simply establishing a framework to protect employees from medical debt — the leading cause of bankruptcy in the United States.

• Claims Cost Transparency: Using Data to Optimize Medical Benefits Costs. Employee benefits are the second largest budget item in employee compensation, with medical benefits consuming the bulk of that cost. Yet, companies with fully insured medical plans often have limited financial transparency and control when it comes to managing these costs. Try viewing the actual, full cost for a broken ankle, and you’ll see that pricing is not so transparent. Companies that know and understand their medical & Rx claims can make decisions that will improve plan utilization and reduce overall costs. Claims cost analysis allows you to drill down into the data and see what you need in your health plan to boost utilization and get your employees and their families better care. Many small and mid-size companies have fully insured plans, allowing for a fixed monthly cost. The carrier creates a pool, lumping your company with others. The carrier may determine your rate based on costs for the entire pool, meaning you’ll pay a set cost whether your company’s claims are higher or lower than average. When it comes to data, however, fully insured plans may not provide transparency or flexibility. They offer some claims data, but the carrier owns all of it, including your high claimant utilization.

• The 2023 specialty drug pipeline. “We’re in a whole new world. The specialty world has taken over,” said Jeffrey Casberg, M.S. Casberg, senior vice president of pharmacy of IPD Analytics, and his colleague, Leslie Fish, Pharm.D.. vice president of pharmacy at the Aventura, Florida, pharmaceutical analytics, and consulting firm, gave an hourlong tour of that world on the final day of the annual meeting of the Academy of Managed Care Pharmacy in San Antonio. More specifically, they thumbnailed the thirty-one specialty drugs in late-stage development that have been or are likely to be approved by the FDA this year. It is a group that includes the first gene therapy for hemophilia A and Duchenne muscular dystrophy, the first treatment for a rare neurological disorder called Friedreich’s ataxia that may have off-label uses, a third anti-beta amyloid drug for Alzheimer’s disease, an oral treatment for Clostridioides difficile that might preferable to treatment delivered rectally that is currently on the market, and three different vaccines for respiratory syncytial virus, one of which is going to have Magic Johnson as a spokesperson. Nearly 80% of the drugs that the FDA is expected to approve this year are specialty drugs, a category that is getting increasingly difficult to define but includes drugs for rare diseases or need special handling.