Drug Channels News Roundup, July 2023: GoodRx + CVS Caremark, Accumulators vs. Patients, Hospitals vs. Taxes, and UnitedHealthcare Prior Auth Humor

Let’s cut through the steamy summer haze with Drug Channels’ refreshing breeze of questions for you to ponder while on your favorite pink beach:

• Why does the biggest PBM need a discount card partner?

• How do copay accumulators affect prescription adherence?

• Do nonprofit hospitals deserve their tax exemption?

Plus, Dr. Glaucomflecken asks: What would happen if UnitedHealthcare hired physicians who practiced evidence-based medicine?

P.S. Join my more than 43,000 LinkedIn followers for daily links to neat stuff. You can also find my daily posts at @DrugChannels on Twitter, where I have more than 16,600 followers. (I recommend that you follow me on LinkedIn, because the quality of comments and engagement is much higher than they are on Twitter. I’m not posting to Threads yet.)

How Prior Auth Solutions Can Empower Patients, Providers and Pharma Field Teams

Today’s guest post comes from Brent Clifton, Vice President of Product Management at CoverMyMeds.

Brent discusses the challenges that patients, caregivers, and providers face when seeking access to medications requiring prior authorization. He explains how an electronic prior authorization solution can reduce delays and help patients start their therapies sooner—especially when patients and brands can play an active role in the process.

Click here to learn about CoverMyMeds’ electronic prior authorization solutions.

Read on for Brent’s insights.

Four Crucial Questions about the Humira Biosimilar Price War

The Humira biosimilar market has arrived!

This month, nine biosimilar versions of adalimumab launched in the U.S. market. As I predicted in 2021, some products launched with list prices that are only slightly lower than Humira’s list price, while others are trying to tempt payers and pharmacy benefit managers (PBMs) with deep list price discounts.

Surprisingly, two PBMs—Express Scripts and OptumRx—will each offer at least one low-list-price biosimilar option on their main national formularies.

Below, I help you understand the current and future market dynamics by posing four questions about drug pricing, rebate walls, patient behavior, the gross-to-net bubble, pharmacy/wholesaler economics, and more.

No biosimilar has the trifecta of being high-concentration, citrate-free, and fully interchangeable. These shortcomings, combined with physician hesitancy, will limit the ability of price to drive adoption. But as I see it, the Humira price war signals that rebate walls will crumble and the gross-to-net bubble will pop. Will payers let Humira go?

Informa Connect’s Medicaid Drug Rebate Program Summit (MDRP)

Informa Connect’s Medicaid Drug Rebate Program Summit (MDRP)
September 18-20, 2023 in Chicago, IL
www.informaconnect.com/MDRP

Drug Channels readers save 10% with code 23DRCH10*

Join Informa Connect and the life science industry on September 18-20, 2023 in Chicago, IL at the 2023 Medicaid Drug Rebate Program Summitto master complex MDRP regulatory guidelines to deliver compliant government pricing and reporting programs.

View the agenda for the 2023 MDRP Summit to see the complete picture – the program, speakers, and more, and visit for further details and to register. Drug Channels readers will save 10% off when they use code 23DRCH10 and register prior to August 11, 2023.*

This annual event provides you and your team unparalleled access to the government regulators creating the rules, policies and regulations, the industry leaders tasked with interpreting them and the manufacturer experts who will be implementing them.

Hear from more than 90 leading experts representing the Acadia Pharma, Ascendis, AstraZeneca, Bristol Myers Squibb, CSL Behring, Eisai, FTC, Genentech, Genmab, Gilead Sciences, GlaxoSmithKline, Helsinn Therapeutics, Kyowa Kirin, Lundbeck, Lupin Pharma, Novartis, OIG, Optum, Pfizer, PhRMA, Sandoz, Takeda, United Therapeutics, Vaitris and many more.

Sessions include coverage on multiple hot topics, including:

• CMS Stacking Rule
• Everything IRA and 304B
• FSS and Government Contracting
• GTN Best Practices
• State Drug Price Transparency and Reporting
• Value Based Agreements
• Bundling, Acquisitions and Divestitures
• AMP Cap Removal
• Rebates, Disputes and GP Calculations
• OIG Perspective on Prescription Drug Pricing and Payment
• And so much more!

View the agenda for the 2023 MDRP Summit to see the complete picture – the program, speakers, and more, and visit for further details and to register. Drug Channels readers will save 10% off when they use code 23DRCH10 and register prior to August 11, 2023.*

*Cannot be combined with other offers or used towards a current registration. Cannot be combined with special category rates or other offers. Other restrictions may apply.

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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).

New SingleCare Pharma Solutions Help Drugmakers Reach Cash-Paying Patients

Today’s guest post comes from Josh Bliss, SVP of Customer Acquisition and Head of Pharma Solutions at SingleCare

Josh discusses the challenges that pharmaceutical manufacturers face connecting with consumers who could benefit from patient financial support programs. He describes SingleCare's new Pharma Solutions, which offers manufacturers the opportunity to market their copay assistance programs directly to SingleCare's millions of monthly prescription discount users.

To learn more about SingleCare's Pharma Solutions, please visit www.singlecare.com/pharmasolutions.

Read on for Josh’s insights.

EXCLUSIVE: For 2023, Five For-Profit Retailers and PBMs Dominate an Evolving 340B Contract Pharmacy Market

Looks like pharmacy and PBM profiteering within the 340B Drug Pricing Program will never go out of style.

Drug Channels Institute’s (DCI) latest analysis reveals that more than 33,000 pharmacy locations—more than half of the entire U.S. pharmacy industry—act as contract pharmacies for the hospitals and other healthcare providers that participate in the 340B program. Over the past 12 months, the number of pharmacies in the program has grown by more than 1,000 locations, which was the slowest growth rate since DCI started tracking this figure more than 10 years ago.

Consistent with our previous research, five multi-billion-dollar, for-profit, publicly traded pharmacy chains and PBMs—CVS Health, Walgreens, Cigna (via Express Scripts), UnitedHealth Group (via OptumRx), and Walmart—account for 75% of all 340B contract pharmacy relationships with covered entities. These contract pharmacy operators’ total estimated gross profits from the 340B program were nearly $3 billion in 2023.

Manufacturers’ contract pharmacy policy changes have slowed profits at pharmacies and PBMs, while triggering change in hospitals’ pharmacy strategies. Read on for my latest effort to pierce these little webs of 340B opacity.

Optimizing Access: Balancing Speed-to-Therapy and Gross-to-Net

Today’s guest post comes from Sahil Naik, Chief of Staff to the CEO at Phil, Inc.

Sahil discusses how manufacturers can balance patients’ access to therapy with gross-to-net (GTN) goals. Visit https://phil.us/ to learn more about how Phil helps improve the patient experience while managing GTN.

Read on for Sahil’s insights.

Drug Channels News Roundup, June 2023: Humira Price War and Mark Cuban, Formulary Exclusions, Oncology Drug Benefits, and Our Wonderful Healthcare System

Happy 247st birthday, America! Before you launch your July 4 festivities, Drug Channels offers some fireworks of our own:

• My $0.02 on the Humira price war—and the role of cost-plus pharmacy pricing

• Fresh evidence that formulary exclusions hurt patients

• Disturbing oncology drug benefit management

Plus, an entertaining explanation of why the U.S. healthcare system is so hard to explain.

P.S. Join my more than 42,000 LinkedIn followers for daily links to neat stuff. You can also find my daily posts at @DrugChannels on Twitter, where I have more than 16,500 followers. (I recommend that you follow me on LinkedIn, because the quality of comments and engagement is much higher than they are on Twitter.)

Informa Connect’s Health Systems & Pharma Partnering Summit

Informa Connect’s Health Systems & Pharma Partnering Summit
August 14-16, 2023 in Boston, MA
www.informaconnect.com/health-systems-partnering
Drug Channels readers save 10% with code 23DRCH10*

View the agenda for Health Systems & Pharma Partnering 2023 to see the complete picture – the program, speakers, and more, and visit www.informaconnect.com/health-systems-partnering for further details and to register. Drug Channels readers will save 10% off when they use code 23DRCH10 and register prior to July 28, 2023.*

Join your colleagues on August 14-16, 2023 at the Westin Copley Place for the Health Systems & Pharma Partnering Summit to optimize strategic partnerships and improve quality, manage costs and enhance patient outcomes. This is a critical opportunity to navigate these complex yet beneficial partnerships with both health systems and life science companies together.

When you join Informa for this groundbreaking think-tank, you’ll find yourself in the company of experts from health systems, pharma/biotech manufacturers, integrated delivery networks, payers, and providers to hear novel case studies, regulatory updates and innovative models aimed at developing and maintaining collaborative, patient-centered partnerships.

Topics being covered include overcoming pharmacy challenges, collaboration strategies across the industry, operational priorities to deliver value-driven engagement, healthcare priorities for lawmakers, impact of the Inflation Reduction Act, legal challenges and financial impact related to 340B, deep dives into challenges related to biosimilars, 340B, white bagging, population health, payer-provider and supplier-partner collaboration, challenge of new therapy development and market access and more.

View the agenda for Health Systems & Pharma Partnering 2023 to see the complete picture – the program, speakers, and more, and visit www.informaconnect.com/health-systems-partnering for further details and to register. Drug Channels readers will save 10% off when they use code 23DRCH10 and register prior to July 28, 2023.*

*Cannot be combined with other offers or used towards a current registration. Cannot be combined with special category rates or other offers. Other restrictions may apply.

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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).

The State of Employers’ Pharmacy Benefits: A Review of 2022 and the 2023 Outlook for Copay Programs (rerun)

This week, I’m rerunning some popular posts while I prepare for today’s live video webinar: PBMs and the Battle Over Patient Support Funds: Accumulators, Maximizers, and Alternative Funding.

Click here to see the original post from January 2023.

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Now that 2023 is underway, let’s review employer-sponsored coverage for prescription drugs and speculate on what’s ahead.

Below I examine the latest data on pharmacy benefits: cost sharing tier structures, copayment vs. coinsurance, and out-of-pocket obligations. As you will see, pharmacy benefit designs again increased the use of coinsurance for specialty and fourth-tier drugs.

These designs significantly raise patients’ out-of-pocket obligations—and contribute to the controversy over copay accumulator adjustment and copay maximizers. In 2023, employers’ savings and PBMs’ profits from these programs will decline—which will trigger a coming crackdown on specialty drug benefits. Beneficiary beware!

P.S. As usual, you will also enjoy some terrible Drug Channels tiers/tears puns.

How Discount Cards Work: A Primer on GoodRx and Its Competitors (rerun)

This week, I’m rerunning some popular posts while I prepare for tomorrow’s live video webinar: PBMs and the Battle Over Patient Support Funds: Accumulators, Maximizers, and Alternative Funding.

Click here to see the original post from May 2023.

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In my March video webinar, I explored how the rapid expansion of patient-paid prescriptions—via cash-pay pharmacies and discount card vendors—is transforming the prescription market.

Below, I follow the dollar when a patient uses a discount card to pay for a generic drug prescription.

As you’ll see, a discount card can save money for consumers by leveraging several quirks of U.S. retail pharmacy pricing. Such cards also enable novel profit streams for both pharmacy benefit managers (PBMs) and the card vendors themselves.

For a deep dive into patient-paid prescriptions, see Sections 4.3. and 12.4.3. of our 2023 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers.

Four Trends That Will Pop the $250 Billion Gross-to-Net Bubble—and Transform PBMs, Market Access, and Benefit Design (rerun)

This week, I’m rerunning some popular posts while I prepare for this Friday’s live video webinar: PBMs and the Battle Over Patient Support Funds: Accumulators, Maximizers, and Alternative Funding.

Click here to see the original post from April 2023.

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Time for Drug Channels Institute’s annual update on the gross-to-net bubble—the ever-growing dollar gap between sales at brand-name drugs' list prices and their sales at net prices after rebates and other reductions.

We estimate that the gross-to-net bubble reached $223 billion for patent-protected brand-name drugs in 2022. If we include brand-name drugs that have lost patent protection and face competition from generic equivalents, the bubble was even higher, at $256 billion. Our latest data appear below.

Four crucial trends will deflate the gross-to-net bubble—thereby disrupting market access strategies, altering pharmacy benefit manager (PBM) profit models, and changing plan sponsor benefit designs. Perhaps it’s time to get ready for the day when SpongeBob SquarePants will depart from Drug Channels.