Sanofi and Bristol Myers on the hook for $916M in do-over of Plavix marketing case and other notes from around the interweb:

• State Halts GLP-1 Weight Loss Drug Coverage for State Employees. Concerning that costs could reach more than $1 billion over the next 6 years, North Carolina opted to stop coverage for the pricey new GLP-1s, saying the contracts between the drugmakers and the PBMs “are all-or-nothing.” The 750,000 public employees enrolled in the plan now must pay out of pocket if they want to take Wegovy or similar drugs. North Carolina initially wanted to save money by limiting prescriptions to patients who first tried lifestyle management programs to lose weight. However, the manufacturer and the state’s pharmacy benefit manager, CVS Caremark, said the state would have to pay full list price for the drugs unless it agreed to allow all patients with a prescription to get them without any preliminary hurdles, in which case the state could receive rebates amounting to a 40% discount.

• Audit of the American Postal Worker’s Union Health Plan’s Pharmacy Operations. “We found that the PBM overcharged the Carrier and the FEHBP $44,882,688 (including lost investment income) by not passing through all discounts and credit related to prescription drug pricing that were required under the PBM Transparency Standards found in the Carrier’s contract with the OPM. Specifically, our audit identified the following six findings that require corrective action. The findings occurred across all years of the auto scope unless otherwise noted.”

• Amazon is expanding its pharmacy footprint. Amazon’s pharmacy business may be coming into its own as it expands its physical presence and eyes increased revenue from the new class of weight loss drugs. After struggling to find its foothold in the U.S. healthcare market since its launch in 2020, in March Amazon announced a partnership with Eli Lilly to deliver its weight-loss drug Zepbound to consumers and expanded its same-day pharmacy delivery service to New York City and greater Los Angeles. Amazon Pharmacy vice-president John Love told the Financial Times at the time that Zepbound and its rivals are expected to generate “a lot of revenue.” To help support those expanded delivery services, on May 29 Amazon Pharmacy opened its first physical location in California, according to the Los Angeles Press-Telegram. It’s not a normal walk-in store, however. The pharmacy sits next to an Amazon fulfillment center in Corona, California, behind two locked doors, and is meant to facilitate same day deliveries. It’s one of twelve locations nationwide, located in eight states, including New York, Indiana, Texas, and Florida.

• Sanofi and Bristol Myers on the hook for $916M. Hawaii has won more than $900 million in a years-old lawsuit over the blood-thinning drug Plavix, in the largest court award in the state’s history. It’s a victory over two of the country’s largest drug companies, who said they plan to appeal. Plavix was marketed as a drug that could help reduce serious cardiovascular events. But in 2014, a state court found Bristol-Myers and Sanofi sold Plavix in Hawaii for 12 years, even though they knew it did not work on many Asians and Pacific Islanders. Judge James Ashford ruled that Sanofi and BMS knew that there was a risk “that about 30% of patients might have a diminished response to Plavix, but they did not update their label. The defendants created an environment where Hawaii prescribing physicians practiced for more than a decade without the necessary information needed to evaluate the serious limitations of this heart medication,” Ashford added.

In the ever-evolving landscape of pharmacy benefit management, few developments have stirred as much excitement—and anxiety—as the introduction of triple agonist GLP-1 Retatrutide. With the potential to revolutionize treatments for diabetes and obesity, this novel drug is making waves. But what exactly is an agonist, and why is Retatrutide causing such a stir?

Understanding Agonists

First, let’s break down what an agonist is. In pharmacology, an agonist is a substance that binds to a specific receptor on a cell and triggers a response, mimicking the action of a naturally occurring substance. Think of it like a key fitting into a lock and turning it. When the key (agonist) binds to the lock (receptor), it opens the door (activates the receptor) to produce a specific effect.

Zepbound, Mounjaro, Wegovy, and Ozempic all function by reducing appetite, but there are key differences in their mechanism of action. Zepbound and Mounjaro are known as “dual-agonist” drugs, while Wegovy and Ozempic are “single-agonist” drugs. These medications activate essential hormone pathways in the body to achieve their effects.

What Makes Retatrutide Special?

Retatrutide stands out because it is a triple agonist. This means it simultaneously activates three different types of receptors:

1. GLP-1 Receptor (Glucagon-Like Peptide-1)
2. GIP Receptor (Glucose-Dependent Insulinotropic Polypeptide)
3. Glucagon Receptor

By targeting these three receptors, Retatrutide offers a multifaceted approach to managing blood glucose levels, enhancing insulin secretion, and potentially promoting weight loss. This multi-receptor activation could provide superior efficacy compared to current single or dual agonist therapies. Enrollees in the clinical trial receiving Retatrutide also experienced improvements in blood pressure and lipid profile.

Here are the detailed results from the Retatrutide study:

Key Observations

• Change in Body Weight: The graphs above illustrate the mean percentage change in body weight at 24 and 48 weeks across different dosage groups, highlighting the significant impact of Retatrutide on weight reduction compared to placebo.
• Weight Reduction Percentages: The bar chart shows the percentage of participants achieving weight reductions of 5%, 10%, and 15% or more at 48 weeks.

The Promise of Retatrutide

• Improved Glycemic Control: By activating the GLP-1 and GIP receptors, Retatrutide can significantly enhance insulin secretion in response to meals, leading to better blood sugar control.
• Weight Management: The activation of these receptors also influences appetite regulation and energy expenditure, potentially aiding in substantial weight loss for individuals with obesity.
• Cardiovascular Benefits: Preliminary studies suggest that Retatrutide may offer cardiovascular benefits, reducing risks associated with diabetes and obesity.

Why Worry?

Despite the promising benefits, the introduction of Retatrutide is not without concerns:

• Side Effects: As with any new medication, there are potential side effects. These could range from gastrointestinal issues to more serious concerns that have yet to be fully understood.
• Long-term Safety: The long-term effects of triple receptor activation are still under investigation. It’s crucial to ensure that the benefits outweigh the risks over extended use.
• Cost and Accessibility: New drugs often come with high price tags, and access can be limited by insurance coverage and healthcare policies. Ensuring that those who need Retatrutide can afford it will be a significant challenge.

Conclusion

As a new pharmaceutical sales rep at Eli Lilly, I toured the manufacturing facility for Cialis. The experience was astounding; advanced robotics handled every step of production, from mixing raw ingredients to pressing and packaging tablets, all without human interaction. Hundreds of tablets were manufactured every minute, a testament to the incredible advancements in pharmaceutical manufacturing technology.

Fast forward to today, and I see the same excitement and potential in the pending launch of Retatrutide. Just as those robotics revolutionized Cialis production, Retatrutide promises to revolutionize the treatment of diabetes and obesity with its triple-agonist approach. However, the cost implications cannot be ignored.

Self-funded employers, already navigating the complexities of healthcare costs, now face the challenge of incorporating this expensive but potentially life-changing medication into their plans. While the potential health benefits of Retatrutide are immense, it is crucial to balance these benefits with the financial realities.

Employers must consider strategies to manage these costs effectively, ensuring that they can provide the best care for their employees without compromising their financial stability. My best advice to you is pick the right pharmacy benefit manager.

As a CHRO, it’s crucial to stay informed about the impact of the CAA on your fiduciary responsibilities in managing pharmacy benefits. Here are ten key aspects in understanding the Consolidated Appropriations Act (CAA) for pharmacy benefit management:

1. Enhanced Fiduciary Responsibility: Prioritize the best interests of plan participants.
2. Transparency Requirements: Demand greater financial transparency from PBMs.
3. Disclosure of Direct and Indirect Compensation: Obtain detailed disclosures on all PBM compensation.
4. Reasonableness of Fees: Ensure PBM fees are reasonable and reflect service value.
5. Annual Reporting Obligations: Review detailed annual reports on drug pricing and utilization.
6. Prohibited Contractual Provisions: Comply with prohibitions on gag clauses and other restrictions.
7. Monitoring and Auditing Rights: Regularly audit PBM activities and data.
8. Plan Sponsor Responsibilities: Actively manage PBM relationships and performance.
9. Participant Disclosure Requirements: Provide clear information to participants about benefits and costs.
10. Penalties for Non-Compliance: Avoid penalties by adhering to CAA requirements.

📚 Continuous Learning is Key 📚

Engage in ongoing education and training to stay updated on regulatory changes and industry best practices. This will ensure you are well-equipped to navigate the complexities of the CAA and maintain compliance, ultimately protecting the interests of your plan participants and organization. Understanding the Consolidated Appropriations Act (CAA) for pharmacy benefit management is a key aspect of plan fiduciary responsibility.

Health plan sponsors must manage plan assets wisely and solely for the benefit of participants and beneficiaries. Fiduciaries are expected to possess expertise in their field or to seek guidance from subject-matter experts. The standard they must meet is that of a prudent expert, not just a well-intentioned layperson. Merely making a good faith effort does not suffice.

The video “Unlocking the Secrets of PBMs: Strategies to Navigate Their Profit Tactics” is an insightful 59-minute presentation designed to equip employers and benefits consultants with the necessary tools to effectively manage and negotiate with pharmacy benefit managers (PBMs). Over the course of the video, viewers are introduced to the various profit-making tactics employed by PBMs and the impact these can have on pharmacy costs and patient outcomes. Mastering PBM negotiations is an essential tool for CHROs, CFOs, and benefits consultants.

Key sections of the video delve into understanding the opaque pricing models that PBMs often use, which can obscure actual drug costs and complicate efforts to ensure fair pricing. The video provides practical strategies to unveil these hidden costs and leverage this transparency in negotiations. It also discusses the importance of contract clarity and how to ensure contracts are devoid of loopholes that could increase costs unexpectedly.

Furthermore, the video highlights the significance of staying informed about industry trends and regulatory changes that can affect PBM contracts. It advises on building a collaborative relationship with PBMs while maintaining a vigilant stance that prioritizes fiduciary responsibilities. For employers and benefits consultants, this video is an essential tool, offering actionable advice on how to reduce pharmacy costs without compromising on the quality of patient care.

This document presents a detailed evaluation of the top 10 clinical programs offered by pharmacy benefit managers (PBMs), which are pivotal for optimizing drug management and enhancing patient care while maintaining cost-effectiveness. The evaluation of top 10 pharmacy benefit manager clinical programs is methodically ranked, each program focusing on various aspects of clinical pharmacy benefit management.

1. Formulary Management: Topped by dynamic formulary adjustments, this program ensures regulatory compliance and the integration of clinical evidence to drive value-based decisions.
2. Specialty Pharmacy Management: This handles complex conditions through specialty pharmacies, emphasizing treatment adherence and efficiency.
3. Prior Authorization: Focused on fraud and waste prevention, this program maintains robust prior authorization processes with an approval rate below 70%.
4. Disease Management: Offers disease-specific guidelines and regular patient monitoring to enhance patient safety and health outcomes.
5. Medication Therapy Management (MTM): A comprehensive review of patient medications is combined with education and adherence programs to improve health impacts.
6. Benzodiazepine Management: This focuses on safe prescribing practices and patient education regarding the risks associated with benzodiazepines.
7. Generic Substitution: Promotes the use of generic drugs to enhance cost transparency and increase generic dispensing rates.
8. Medication Adherence: Utilizes medication synchronization and refill reminders to improve the proportion of days covered.
9. Opioid Management: Enforces guidelines on opioid prescribing, patient education on risks, and drug take-back options to manage opioid use effectively.
10. Step Therapy: Implements clear, evidence-based guidelines for medication sequences to ensure clinical and cost-effectiveness.

Each program is backed by best practices and involves key stakeholders like Pharmacy Directors, Healthcare Providers, and Pharmacy & Therapeutics Committees, ensuring a holistic approach to pharmacy benefits management. This ranking is crafted to assist Chief Human Resources Officers (CHROs) and Chief Financial Officers (CFOs) in making informed decisions about which clinical programs can best meet their organizational needs, align with financial goals, and ensure patient safety and satisfaction.

New lawsuit targets opioid pharmacy benefit managers and other notes from around the interweb:

• New Lawsuit Targets Opioid Pharmacy Benefit Managers. The case is before federal Judge Dan Aaron Polster of the United States District Court for Northern Ohio based in Cleveland. “Judge Polster recently opened a new bellwether track of cases against Express Scripts and OptumRx, two of the three PBMs with the largest market share in the United States,” according to the National Opioid Litigation letter. The other company in that top three is CVS Caremark, a subsidiary of CVS Health, that was included in a recent $10 billion settlement that also involved Walgreens…”About those companies, Marcus told the commissioners, “They chose profits over doing the right thing.”

• Fiduciary Duty Update: PBM Audit is Now Mandatory Protocol. The revelation that a drug costing over $10,000 in the market could be sourced for $28.40 has sent shockwaves through the industry, illustrating a glaring oversight in PBM management. Auditing your PBM is not merely a best practice; it is a critical safeguard against financial inefficiency and legal liabilities. Audits reveal discrepancies in billing, conflicts of interest, and non-compliance with contract terms — issues that, if unaddressed, could lead to breach of fiduciary claims.

• Audit of the American Postal Worker’s Union Health Plan’s Pharmacy Operations. “We found that the PBM overcharged the Carrier and the FEHBP $44,882,688 (including lost investment income) by not passing through all discounts and credit related to prescription drug pricing that were required under the PBM Transparency Standards found in the Carrier’s contract with the OPM. Specifically, our audit identified the following six findings that require corrective action. The findings occurred across all years of the auto scope unless otherwise noted.”

• Why Are Cash Prices Lower Than Health Insurance Negotiated Prices? Growing evidence demonstrates a counterintuitive phenomenon in healthcare: the cash price is often cheaper than insurance prices for the same service or product. Cash prices are unilaterally determined by a provider, while insurance prices are bilaterally negotiated between a provider and an insurance company. Don’t insurance companies presumably possess more bargaining power than individual patients? Our study found that among common shoppable services—such as lab tests, imaging, and joint replacements—half of U.S. hospitals set cash prices lower than their median insurance negotiated prices. Cash price being cheaper than insurance prices has also been documented for prescription drugs.

Ranking the top utilization management (UM) programs used by Pharmacy Benefit Managers (PBMs) can be complex due to the proprietary nature of specific tools and strategies employed by different organizations. However, several key types of UM programs are commonly recognized as effective in managing pharmacy benefits and controlling costs while ensuring patient care. Here’s TransparentRx’s ranking of the top ten pharmacy benefit manager utilization management programs:

Pharmacy benefits must be carefully managed to ensure people receive cost-effective treatment, improving their well-being and helping them lead happier, longer lives. This also enables employers to maintain a healthy and engaged workforce. These UM programs form the core of what many top PBMs use to manage drug utilization effectively. Each program has its strengths and plays a critical role in balancing cost containment with the provision of high-quality care. The specific effectiveness and ranking can vary depending on the specific health populations managed and the overall strategy of the PBM.

Audit of the American Postal Worker’s Union Health Plan’s Pharmacy Operations and other notes from around the interweb:

• Audit of the American Postal Worker’s Union Health Plan’s Pharmacy Operations. “We found that the PBM overcharged the Carrier and the FEHBP $44,882,688 (including lost investment income) by not passing through all discounts and credit related to prescription drug pricing that were required under the PBM Transparency Standards found in the Carrier’s contract with the OPM. Specifically, our audit identified the following six findings that require corrective action. The findings occurred across all years of the auto scope unless otherwise noted.”

• Why Are Cash Prices Lower Than Health Insurance Negotiated Prices? Growing evidence demonstrates a counterintuitive phenomenon in healthcare: the cash price is often cheaper than insurance prices for the same service or product. Cash prices are unilaterally determined by a provider, while insurance prices are bilaterally negotiated between a provider and an insurance company. Don’t insurance companies presumably possess more bargaining power than individual patients? Our study found that among common shoppable services—such as lab tests, imaging, and joint replacements—half of U.S. hospitals set cash prices lower than their median insurance negotiated prices. Cash price being cheaper than insurance prices has also been documented for prescription drugs.

• Fiduciary Duty Update: PBM Audit is Now Mandatory Protocol. The revelation that a drug costing over $10,000 in the market could be sourced for $28.40 has sent shockwaves through the industry, illustrating a glaring oversight in PBM management. Auditing your PBM is not merely a best practice; it is a critical safeguard against financial inefficiency and legal liabilities. Audits reveal discrepancies in billing, conflicts of interest, and non-compliance with contract terms — issues that, if unaddressed, could lead to breach of fiduciary claims.

• How GoodRx Helped Steal $7 From My Pharmacy. GoodRx, primarily known as a platform for obtaining prescription coupons and tracking drug prices, interacts with Pharmacy Benefits Managers (PBMs) in a way that’s distinct from traditional PBM operations. In essence, GoodRx leverages the existing PBM infrastructure to provide discounted prices directly to consumers, often bypassing the more traditional insurance-based prescription purchasing pathway. For benefits consultants and employers, understanding this interaction is crucial in advising on healthcare strategies that maximize both cost efficiency and patient outcomes. Employers need to consider how tools like GoodRx fit into a broader benefits design, particularly in terms of how they affect out-of-pocket costs for employees and the overall usage of pharmacy benefits managed under traditional PBM contracts.

In our webinar, “Revolutionizing Pharmacy Benefits by Disrupting the Status Quo and Driving Down Costs,” we delve into the innovative strategies reshaping the landscape of pharmacy benefits management (PBM). By challenging conventional approaches and implementing cutting-edge solutions, we’re driving down costs while enhancing patient outcomes.

Why You Should Watch:

1. Gain Insight: Learn about groundbreaking methodologies transforming pharmacy benefits, equipping you with the knowledge to navigate this evolving industry.
2. Cost Reduction Strategies: Discover practical approaches to reducing pharmacy costs without compromising the quality of care, crucial for businesses seeking to optimize their healthcare spending.
3. Patient-Centric Solutions: Explore how our innovative techniques prioritize patient well-being, ensuring better health outcomes while containing expenses.
4. Industry Disruption: Stay ahead of the curve by understanding the latest disruptions in the PBM sector and how they can benefit your organization.
5. Fiduciary Standard of Care: Understand the importance of adopting a fiduciary standard of care in pharmacy benefits management, aligning with best practices and ethical standards.

Who Should Watch:

• Benefits Consultants: Enhance your expertise in PBM to better serve your clients and provide them with actionable strategies to control healthcare costs.
• Human Resources Managers: Gain insights into innovative approaches for managing pharmacy benefits, helping you make informed decisions that benefit your employees and your bottom line.
• Employers: Learn how to optimize your pharmacy benefits program to achieve cost savings while ensuring your employees receive high-quality care.
• Healthcare Professionals: Stay abreast of industry trends and advancements in pharmacy benefits management, enabling you to deliver more effective patient care within your organization.

Watch on-demand as we revolutionize pharmacy benefits together, driving down costs while prioritizing patient well-being. Let’s disrupt the status quo and shape the future of healthcare together!

In today’s rapidly evolving healthcare landscape, managing pharmacy benefits is not just about containing costs—it’s about crafting a synergy of quality care, accessibility, efficiency, and participant satisfaction. At TransparentRx, we understand that every aspect of pharmacy benefit design can significantly impact the health and well-being of the participants it serves. Let’s delve into the four broad issues that underpin an effective pharmacy benefit design.

1. Quality: The Pillar of Care

Quality in pharmacy benefits is threefold: care structure, processes, and outcomes. A robust care structure is foundational, ensuring that participants have access to essential medications without unnecessary delays or hurdles. The process, from prescription to pill delivery, must be streamlined, clear, and consistently monitored for potential improvements.

Outcomes are the ultimate measure of quality. At TransparentRx, we prioritize the clinical effectiveness of the medications provided and the positive health outcomes for the participant. This includes not only the resolution of the condition being treated but also monitoring for potential drug abuse, interactions, and side effects.

2. Accessibility: Removing Barriers

Accessibility goes beyond the physical availability of medications. It encompasses the elimination of financial, transportation, and geographical barriers that participants may face. TransparentRx champions affordable options without sacrificing quality. Whether it’s negotiating better prices or embracing mail-order services, we ensure that medications are within reach, both geographically and financially.

Transportation and geographical challenges are addressed by a network of pharmacies and the use of innovative delivery methods. By enhancing our telehealth and mail-order services, we bring the pharmacy to the participant’s doorstep, no matter where they live.

Understanding the distinctions between effective and ineffective benefit design practices is crucial. Below, we present a table contrasting strong (good) examples of benefit design with practices that should be avoided (bad) for each of the four broad issues:

By recognizing the stark contrast between these examples, employers, brokers, and consultants can more effectively evaluate and select pharmacy benefit plans that align with the fiduciary standard of care and participant-centric values. TransparentRx stands ready to guide you through the intricacies of these issues, ensuring that your pharmacy benefit design is both cost-effective and highly beneficial to your participants.

3. Efficiency: Maximizing Resources

Efficiency in pharmacy benefit design means accomplishing plan objectives with the least expensive combination of resources—without compromising on quality. At TransparentRx, we leverage InsourceRx data analytics to understand usage patterns, eliminate waste, and prevent fraud.

We assess the therapeutic equivalents and generic options, ensuring the most cost-effective medications are available. By balancing the cost against clinical effectiveness, we provide a plan that respects both the participant’s health and the bottom line.

4. Participant Satisfaction: The Heart of Our Mission

The true measure of a successful pharmacy benefit design is participant satisfaction. It reflects the ease of using the plan, the quality of the interactions with pharmacy staff, and the clarity of information provided. TransparentRx takes pride in our Net Promoter Score (NPS) of 86, which is a testament to our commitment to participant satisfaction.

This score significantly surpasses the industry average NPS for pharmacy benefit managers, reflecting the exceptional experience participants have with our services. An NPS of 86 indicates that a vast majority of our clients are not just satisfied, but are enthusiastic advocates for our brand, confident in recommending our services to others.

Conclusion

Pharmacy benefits management is a complex, multifaceted endeavor. By focusing on quality, accessibility, efficiency, and participant satisfaction, TransparentRx crafts a pharmacy benefits plan that not only meets but exceeds expectations. Our commitment to a fiduciary standard of care ensures that every decision we make is in the best interest of the participants we serve—helping our nation look better, feel better, and live longer.