Five Takeaways from the Big Three PBMs’ 2022 Formulary Exclusions

For 2022, the three largest pharmacy benefit managers (PBMs)—Caremark (CVS Health), Express Scripts (Cigna), and OptumRx (United Health Group)— increased the number of drugs they excluded from their standard formularies.

Each exclusion list contains 400 to 500 products. Growth in the number of excluded drugs slowed, due partly to the fact that so many drugs have already been dropped from PBMs’ formularies.

Below, I highlight five observations about this year’s lists, including unexplainable differences in how PBMs handle specialty drugs, biosimilars, and insulin.

I also offer some thoughts on non-medical switching and what we still don’t know about how exclusions affect patients.

Let me know what you think by commenting below or on social media.

NEW: The Drug Channels 2022 Video Webinar Series

Join Dr. Adam J. Fein, CEO of Drug Channels Institute (DCI), for three live video webinars during 2022. These live, interactive events will be broadcast via Zoom from the Drug Channels Video studio in beautiful downtown Philadelphia.

Click here to order the Drug Channels 2022 Video Webinar Series

During these events, Dr. Fein will address the latest issues confronting the U.S. drug channel. Topics will be determined based on what’s happening—trends, policy changes, company announcements, and more. He’ll share DCI’s latest market data to help you stay on top of new developments. You will be able to use these events as both a capstone of your current learning and a touchpoint for the future.

The three events are scheduled for 12:00 p.m. to 1:30 p.m. ET on:

• April 22, 2022

• July 29, 2022

• December 16, 2022 (Drug Channels Outlook 2023)

PLUS: During each webinar, Dr. Fein will give participants an opportunity to unmute themselves and ask live questions. And after each event, each registrant will receive an email with links to register to view a replay of the event and to download the full slide deck.

Read on for a video invite and full details on pricing, including substantial discounts for multiple sites.

The 340B Rebate Model: A Solution to the Contract Pharmacy Controversy

Today’s guest post comes from Jeremy Docken, Founder and Chief Strategy Officer at Kalderos.

Jeremy describes Kalderos’ 340B rebate model. He discusses an independent research organization’s study of the 340B rebate model’s impact on covered entities’ cash flow.

To learn more, download the whitepaper: The Kalderos 340B Rebate Model In Action: Ensuring a Thriving and Sustainable 340B Program.

Read on for Jeremy’s insights.

The Retail Pharmacy Outlook for 2022

As I have highlighted in previous posts, retail pharmacies are experiencing a period of intense competition that continues to pressure prescription profits. What's more, the pharmacy shakeout is accelerating, as smaller competitors exit and larger companies reduce store count. 

In the video below, I provide a brief overview of key challenges facing retail pharmacy this year.

The video is excerpted from my Drug Channels Outlook 2022 video webinar. If you missed the live event, you can register to watch a replay.

Enjoy!

PCMA Business Forum

PCMA Business Forum
February 28 – March 1, 2022
JW Marriott Grande Lakes | Orlando, FL
Register Today!
www.pcma.com/businessforum

The PCMA Business Forum is PCMA's largest business networking and educational conference. PCMA’s PBM Members send a large number of executives from relevant business units including pharma and trade relations, specialty pharmacy, clinical and patient care services, and the c-suite. Dynamic conference activities for this two-day event include:

• 20+ timely and thought-provoking educational sessions featuring industry thought leaders. New for 2022, sessions will be broken out into three tracks:
• Strategic Insights – Our industries’ senior most thought leaders and decision makers (main stage sessions)
• Specialty Pharmacy insights and trends (breakout session track)
• Clinical and Patient Care collaboration (breakout session track)
• Pre-recorded PBM member company webinar briefings (for manufacturer registrants only)
• More than 15 hours of CPE sessions
• Dedicated time and private facilities for customer meetings
• Pre-conference networking through the virtual conference platform. The virtual platform includes a full attendee list, the ability to message and send meeting requests to other attendees, hotel maps and meeting room locations, and much more

Register Today!

Contact PCMA
Please contact Kayla Firriolo (kfirriolo@pcmanet.org) with questions or to request further information.

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The content of Sponsored Posts does not necessarily reflect the views of Pembroke Consulting, Inc., Drug Channels, or any of its employees. To find out how you can promote an event on Drug Channels, please contact Paula Fein (paula@drugchannels.net).

Tales of the Unsurprised: Brand-Name Drug Prices Fell for the Fourth Consecutive Year

Reality has again failed to cooperate with the politically motivated cries of “skyrocketing drug prices” or anecdotes about companies “jacking up prices” (as President Biden recently claimed).

Brand-name drug prices continue to decline, while the prices of other healthcare products and services continue to rise. For 2021, brand-name drugs’ net prices dropped for the fourth consecutive year. Meanwhile, brand-name drug list prices grew more slowly than overall inflation. What’s more, we project that the gross-to-net bubble for patent-protected brand-name drugs will exceed $200 billion in 2021. See our updated analysis below.

The factors that drive declining brand-name drug prices remain for 2022, suggesting that these trends will continue.

Pharmaceuticals account for less than 15% of U.S. healthcare spending—but absorb 99% of the political heat and attention. Let’s hope that this peek through the truth binoculars intrudes on any future legislative attempts to address drug pricing and the reimbursement system.

Drug Channels News Roundup, December 2021: CAR-T Profits, UM Boom, Health Plans vs. Experts, Confused Physicians, and Health Insurance Explained

Happy New Year, everyone! We made it through a challenging 2021. Ring in 2022 with these noisemakers from the Drug Channels party bag:

• Hospitals earn incredible markups on CAR-T therapies

• Utilization management booms

• Health plans often ignore clinical guidelines

• Benefit designs flummox physicians

Plus: an awesomely concise summary of U.S. health insurance.

P.S. Please join the more than 13,100 consumers of my daily commentary and links to neat stuff at @DrugChannels on Twitter. You can also find my daily posts on LinkedIn, where I have more than 22,000 followers.

How and Why I Was Overcharged by Penn Medicine and My Blue Cross Health Plan: A True Story (rerun)

This week, I’m rerunning some popular posts while I prepare for today's live video webinar: Drug Channels Outlook 2022. See you soon!

Click here to see the original post and comments from September 2021.

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Sometimes, a little knowledge can be a bad thing.

I want to share with you, dear reader, the strange but true tale of my recent foray into the wonderful world of hospital price transparency for routine lab services.

I discovered—with great effort—that the rates my health plan negotiated with the largest local health system in Philadelphia were greater than the self-pay, cash price. Ultimately, my baffling and unexpected out-of-network bill required me to pay more out-of-pocket than the total cash price.

This tale neatly summarizes why so many people hate our healthcare system—and why the average patient will have trouble benefiting from transparency regulations.

How CVS Health Drives Cardinal Health’s Distribution Financials (rerun)

This week, I’m rerunning some popular posts while I prepare for tomorrow's live video webinar: Drug Channels Outlook 2022. Hope you can join me!

Click here to see the original post and comments from September 2021.

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Cardinal Health recently released the annual report for its 2021 fiscal year, which ended on June 30. See the links below.

Today, I delve into the financials behind Cardinal’s relationship with its largest customer, CVS Health. In Cardinal’s 2021 fiscal year, CVS purchased more than $42 billion in pharmaceuticals from the wholesaler—about double the figure from 10 years ago. The new report also reveals that CVS Health’s payment terms with Cardinal give the wholesaler an often-overlooked cash flow benefit.

I also compare Cardinal’s relationship with CVS to McKesson’s relationship with CVS. The two wholesalers sell more than $90 billion in pharmaceuticals to CVS Health—making it the largest U.S. drug purchaser.

Like McKesson, however, Cardinal Health has discovered that CVS is its worst best friend.

A Video History of Pharmacies and Prescription Prices: From Soda Fountains to GoodRx (rerun)

This week, I’m rerunning some popular posts while I prepare for this Friday’s live video webinar: Drug Channels Outlook 2022.

Click here to see the original post and comments from August 2021.

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Charlotte Morabito at CNBC has put together “Why Pharmacies Overcharge,” an entertaining and provocative video on the pharmacy industry and its generic prescription pricing.

It’s definitely worth your time. I especially enjoyed the cool visualizations of Drug Channels Institute’s industry data. Links below.

The video covers the history of pharmacy, from the “Soda Fountain Era” to “Lick, Stick, and Pour” to the rise of PBMs and GoodRx. 

It also includes a wide variety of expert perspectives, including $0.02 from your friendly neighborhood blogger at Drug Channels. See the list below.

Grab some popcorn and enjoy the show!

PBMs and Drug Spending in 2020: Data from CVS Health (sort of), Express Scripts, Navitus, and WellDyne (rerun)

This week, I’m rerunning some popular posts while I prepare for this Friday’s live video webinar: Drug Channels Outlook 2022.

Click here to see the original post and comments from July 2021.

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Since 2012, Drug Channels has examined commercial drug spending using the annual trend reports published by the largest PBMs.

This year, we review 2020 data on commercial plan sponsor clients of CVS Health and Express Scripts along with two smaller PBMs—Navitus and WellDyne. As you will see below, plan sponsors experienced another year of single-digit growth in overall pharmacy benefit drug spending.

For specialty drugs, utilization—more people taking more prescriptions—remained the driving force behind this higher spending. Specialty drug costs grew slowly—or even declined.

I’m sad to report that this year’s analysis is skimpier than usual. CVS Health has published only a bare bones summary, while Prime Therapeutics, MedImpact, and other large PBMs have stopped publishing trend reports. I document this disappointing state of affairs below.

Read on as I spread all the the k-poppin' details.

Why GoodRx—Not Amazon—May Be the True PBM Disrupter (rerun)

This week, I’m rerunning some popular posts while I prepare for this Friday’s live video webinar: Drug Channels Outlook 2022.

Click here to see the original post and comments from August 2021.

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The generic prescription market is being disrupted—but not by the big, bad spaceman from Seattle.

Instead, consider how GoodRx is affecting patients, payers, and PBMs.

Below I summarize the latest financial results for GoodRx’s discount card business. We estimate that the company accounted for $4.1 billion in U.S. prescription revenues for 2021. That’s about six times its 2016 figure.

GoodRx and its discount card competitors profit by incentivizing people to bypass their own insurance plans. Meanwhile, our crazy pharmacy pricing system deters pharmacies from pursuing consumer-driven pricing and PBMs from undercutting their own clients.

Consequently, discount cards could become the force that upends PBMs’ pharmacy benefit economics, plan sponsors’ decisions, and the entire generic market. Should PBMs continue to profit from discount cards’ rapid growth…while ignoring the risk that this growth could undermine the value of their benefit management services?

Read on and see what you think.