Don’s Story: Patients Shouldn’t Have to be Resilient to Get Their Medications

Today’s guest post comes from Megan Marchal, Director of Specialty Strategy at CoverMyMeds.

Megan shares the story of Don, a cancer patient who struggled to access and afford his medications. She describes how human care plus an innovative, technology-driven patient support solution can help patients start therapy and get on the road to recovery.

To learn more about CoverMyMeds’ specialty therapy solutions, visit Booth 1519 at Asembia's Specialty Pharmacy Summit in Las Vegas, April 30-May 4, 2023. Additionally, sign up for CoverMyMeds’ on-site recaps from the summit.

Read on for Megan’s insights.

Drug Channels News Roundup, April 2023: OptumRx’s Biosimilar Nonsense, Accumulator Inequity, Amazon Redux, AFPs, and My Meeting with Mark Cuban

Baseball season is here! While we wait for the Phillies turnaround, let’s oil up our gloves, lace up our cleats, and run the bases around this month's biggest hits:

• Foul ball: OptumRx prefers higher prices for the first Humira biosimilar (SEE UPDATE BELOW)

• Strikeout: Copay accumulators hurt health equity

• Bench warmer: Surprise? Amazon has still not disrupted healthcare

• Spitting mad: Shady alternative funding programs (AFPs) face more scrutiny

Plus, I sit down with Mark Cuban—and take a selfie.

P.S. Join my nearly 41,000 (!) LinkedIn followers for daily links to neat stuff. You can also find my daily posts at @DrugChannels on Twitter, where I have more than 16,000 followers. (I recommend that you follow me on LinkedIn, because the quality of comments is much, much higher than they are on Twitter.)

Prescribers More Likely to Choose Brands with Automated Processes for Buy-and-Bill Copay Assistance

Today’s guest post comes from Ticia Cawley, VP of Client Solutions at ConnectiveRx.

Ticia reviews four interim findings from ConnectiveRx's survey of buy-and-bill prescribers and their support staff. The survey reveals new insights about how practices evaluate automation and digital tools for provider-administered specialty therapies.

To learn more, register for ConnectiveRx’s free online panel discussion on May 17th at 1:00 p.m. ET: Automation and Ease: The Future of Buy-and-Bill. Ticia will be joined by a buy-and-bill brand leader and a medical professional.

Read on for Ticia’s insights.

The Inflation Reduction Act: 10 Predictions About Market Access and Drug Channels

Like it or not, the Centers for Medicare & Medicaid Services (CMS) is barreling ahead with its implementation of the Inflation Reduction Act of 2022 (IRA). Last Friday was the last day to submit comments on CMS's initial guidance on the drug price negotiation program.

The IRA will alter many crucial aspects of the Medicare program and the overall drug channel. To help you anticipate what’s ahead, below I highlight 10 predictions on how the IRA will impact drug prices, demand for prescription drugs, Part D plan strategies, rebates, manufacturers’ revenues, retail pharmacies, and more.

While this is a longer-than usual post, I can still only barely scratch the surface of the many far-reaching effects of this legislation. As always, I encourage you to share your own thoughts in the comments below or on social media.

Digital Transformation: Facilitating Healthcare Provider and Patient Behavior Change

Today’s guest post comes from Edward Hensley, Chief Commercial Officer at AssistRx.

Edward discusses how a technology-first approach automates manual processes for therapy initiation. He argues that such an approach can increase patient adherence, speed access to therapy, and improve the healthcare providers’ workflow.

To learn about AssistRx’s technology-first solutions, click here to schedule a meeting at Asembia’s Specialty Pharmacy Summit.

Read on for Edward’s insights.

DCI’s Top 15 Specialty Pharmacies of 2022: Five Key Trends About Today’s Marketplace

In Drug Channels Institute’s list of the top 15 pharmacies of 2022, we show that central-fill, mail pharmacies operated by large PBMs and health insurers have displaced retail chains as the largest prescription drug dispensers by revenues.

To complement that broader ranking, we rummaged around our DreamHouse to update our exclusive list of the top 15 pharmacies based on specialty drug dispensing revenues in 2022.

For 2022, pharmacy benefits managers (PBMs) and insurers expanded their dominance over specialty dispensing, though both hospitals and physician practices are growing their share of the market. The top three PBM-owned specialty pharmacies accounted for nearly two-thirds of prescription revenues from pharmacy-dispensed specialty drugs. As predicted last year, Walgreens’ specialty pharmacy business has collapsed, which led to a slightly less concentrated industry.

Read on for additional observations about hospitals, independent pharmacies, the dynamics that created this market structure, and why life in plastic is fantastic.

Key Trends in Medical Benefit Contracting and Value-Based Agreements

Today’s guest post comes from Heather Roulston, Market Research Manager at MMIT.

Using MMIT’s proprietary data, Heather demonstrates that contracting for medical benefit drugs is now common for many therapeutic areas. She then highlights how manufacturers and payers are adopting value-based agreements (VBA) for medical benefit products—although VBA usage varies widely across therapeutic area. Heather also shares data on payers’ site-of-care management strategies.

For additional market insights, click here to learn about MMIT’s Biologics & Injectables Index.

Read on for Heather’s insights.

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

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.

Brand-Name Drug Prices Fell for the Fifth Consecutive Year—And Plummeted After Adjusting for Inflation (rerun)

This week, I’m rerunning some popular posts while I prepare for today’s live video webinar: Discount Cards, Cost-Plus Pharmacies, and PBMs: Trends, Controversies, and Outlook.

Click here to see the original post and comments from January 2023.

---

Time for the Drug Channels annual reality check on drug pricing. The data once again tell a different story than you might read in your favorite politician’s Twitter feed or misleading news reports.

For 2022, brand-name drugs’ net prices dropped for an unprecedented fifth consecutive year. What’s more, after adjusting for overall inflation, brand-name drug net prices plunged by almost 9%.

The factors behind declining drug prices will remain in the coming years—and become even stronger due to forthcoming changes in Medicare and Medicaid. Employers, health plans, and PBMs will determine whether patients will share in this ongoing deflation.

Read on for details and make up your own mind. And please pass the news along to the drug pricing flat earthers (#DPFE) who refuse to accept that brand-name drug prices are falling—or that prescription drug spending is a small and stable portion of overall U.S. healthcare expenditures.

Even a purple gorilla professor understands these facts.

The Warped Incentives Behind Amgen’s Humira Biosimilar Pricing–And What We Can Learn from Semglee and Repatha (rerun)

This week, I’m rerunning some popular posts while I prepare for tomorrow’s live video webinar: Discount Cards, Cost-Plus Pharmacies, and PBMs: Trends, Controversies, and Outlook.

So far, it appears that PBMs are neither preferring Amgen's Humira biosimilar nor embracing the low-list/low-rebate version. In February, AbbVie stated that U.S. Humira sales would be decline by about 37% in 2023—which is at the lower end of its previous erosion projection of 35% to 55%. Much more to come. Click here to see the original post and comments from February 2023.

---

As you've surely heard, Amgen has just launched Amjevita, the first non-interchangeable biosimilar of Humira. Our crazy drug channel led Amgen to launch both a high-list/high-rebate and a low-list/low-rebate version of the drug. Its strategy echoes the pricing of the first interchangeable insulin biosimilars—as I predicted in 2021.

Unfortunately, we should expect most PBMs and plan sponsors to embrace the high-list/high-rebate version. The plans that adopt the higher-priced biosimilar will get bigger rebates, while patients with coinsurance and deductibles end up paying more out-of-pocket.

As Mark Twain said: “History doesn’t repeat itself—but it often rhymes.” So, below, I revisit the surprising market dynamics for the interchangeable insulin biosimilars and highlight Amgen’s experience lowering the list price of its PCSK9i product. The story is more complex than you might expect, so perhaps there is hope that low-list-price versions will connect.

CVS, Walgreens, and Walmart Keep Position in 2023 Part D Preferred Networks—While Kroger Bails Over its Express Scripts Blowup (rerun)

This week, I’m rerunning some popular posts while I prepare for this Friday’s live video webinar: Discount Cards, Cost-Plus Pharmacies, and PBMs: Trends, Controversies, and Outlook.

One follow-up to this rerun: Kroger’s participation as a preferred pharmacy declined significantly due to its Express Scripts relationship. Based on early 2023 enrollment data, Kroger is preferred in plans that enrolled only 11.8 million people—a decline of 33% from the 2022 figure. See Exhibit 154 of our new 2023 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers.

Click here to see the original post and comments from December 2022.

---

In Preferred Pharmacy Networks in 2023’s Medicare Part D Plans: Cigna, CVS Health, Humana, UnitedHealthcare, WellCare, and More, I highlighted how those networks have taken over the world of stand-alone Medicare Part D prescription drug plans (PDP) and become a major presence in Medicare Advantage prescription drug (MA-PD) plans.

Today, I examine the seven largest retail chains’ 2023 participation in the 22 major 2023 Part D preferred networks that the eight largest plan sponsors will offer. As always, I offer you a handy table for scoring each chain’s participation and changes from 2022 to 2023.

As you’ll see, Kroger’s decision to exit Express Scripts commercial pharmacy networks has had negative ramifications for its Part D position. Kroger will be out-of-network—not just non-preferred—in the major Part D networks for which Express Scripts acts as the PBM. That will be  a key factor behind its $1+ billion revenue hit.

The Big Three PBMs’ 2023 Formulary Exclusions: Observations on Insulin, Humira, and Biosimilars (rerun)

This week, I’m rerunning some popular posts while I prepare for this Friday’s live video webinar: Discount Cards, Cost-Plus Pharmacies, and PBMs: Trends, Controversies, and Outlook.

Click here to see the original post and comments from January 2023.

---

For 2023, the three largest pharmacy benefit managers (PBMs)—Caremark (CVS Health), Express Scripts (Cigna), and OptumRx (United Health Group)—have again increased the number of drugs they exclude from their standard formularies.

Each exclusion list now contains about 600 products. Growth in the number of excluded drugs slowed for the second year, due partly to the fact that so many drugs have already been dropped from PBMs’ formularies.

Below, I highlight four takeaways from this year’s lists, including a look at biosimilar insulin and the forthcoming biosimilar competition for Humira. I also note some troubling research on the patient impact of exclusions—although much remains unknown.

As always, I welcome your comments below or on social media.