Tim Crum PharmD, BCGP’s Post

Late last week, the FTC sued the three largest #PBMs over rigging #pharma supply chain competition in their favor, resulting in artificially inflated #insulin prices for some patients. The lawsuit alleges that the Big 3 PBMs have created a “perverse” rebate system that favors higher-priced insulin products even when more affordable insulins with lower list prices are available. Below are a few of my takeaways, with the full story published in today’s EMARKETER Digital Health Briefing (link in comments for clients). ◾ I found it interesting that the agency targeted insulin prices specifically. No doubt insulin list prices have skyrocketed over time, but it’s also noteworthy to point out that 3 companies—which make up about 90% of the US market for insulin—have each recently slashed list prices for certain insulins while limiting patients’ out-of-pocket costs with monthly caps. Still, while the FTC’s lawsuit is against the PBMs, it warned that it may recommend suing these insulin manufacturers. ◾It’s likely that the FTC is looking to set a precedent with insulin prices that could apply to other prescription drugs in the future. ◾Ultimately, the FTC is right in taking issue with the convoluted US healthcare system that lets the Big 3 PBMs—and the health insurers they’re affiliated with—have outsized influence over medication pricing and access. PBMs and health plans ultimately decide what a patient pays at the pharmacy counter. ◾And nobody has an answer or a solution. Whenever PBMs and pharma manufacturers are asked why prescription drug prices are high for so many consumers, each side blames the other party. This is exactly how it played out following the FTC’s lawsuit. Would love to hear any thoughts on what folks think will come from this major development!

The bill aimed to address misaligned incentives within #pharmacy benefit managers (#PBMs), who negotiate #drug prices on behalf of insurers and employers. Proposed measures included increasing transparency and decoupling PBM profits from the rebates they negotiate, which have been criticized for inflating drug prices. The bill's collapse means these reforms are delayed. Despite the bill's failure, there is a growing #bipartisan consensus on the need to tackle flawed PBM business models. Both Republicans and Democrats, including President-elect Donald Trump, have signaled intent to take action against PBMs, indicating that future reforms may still be on the horizon. PBMs have been criticized for practices that may contribute to higher drug prices, such as prioritizing high-rebate drugs. The absence of reform means that these practices may continue, potentially affecting drug affordability and access for consumers.

Drug prices have risen almost 40% over the past decade, according to a new tracker. by Justine Fisher The cost of prescription medications in the U.S. has increased 37% since 2014, far surpassing the rate of inflation, according to data from drug savings company GoodRx. Though the price increases have slowed this year in comparison to the past decade, the higher costs are raising out-of-pocket expenses for consumers. The average American spends $16.26 out of pocket per prescription, according to the data. “When things increase … inevitably, they do trickle down to consumers, especially those who are in a high deductible plan or who don’t have insurance or find themselves paying substantially out of pocket,” said GoodRx director of research Tori Marsh. https://lnkd.in/gh-Z-um4

US prescription drug costs have risen by 37% since 2014, far exceeding the rate of inflation and resulting in higher out-of-pocket costs for Americans, according to GoodRx's prescription drug tracker. The average American currently pays $16.26 out-of-pocket per prescription drug, though price increases have slowed down this year compared with the last 10 years.

Disfavoring Generics: A Point of PBM and #340B Consensus Take a look at Brian Reid insightful post (in the comments) discussing PBMs’ perverse incentive to not place generics on a generic copay tier. In our rebate crazy world, the $ to be made from high list/high rebate drugs leads PBMs to force patients to pay higher copays on generic drugs drugs as an engine of PBM and affiliated plan profitering. What I’d add here is that 340B covered entities have the same incentive. Disafavrong generics is one of the places where PBMs and 340B covered entities push seamlessly in the same direction. The PBMs create formularies and utilization management hurdles that favor high list/high rebate drugs over generic equivalents, and 340B covered entities often switch patients to those same drugs, a task made easier by the PBM formularies and UM. This famous (infamous?) slide from a 340B conference back in the day makes the point with brutal clarity. From a 340B profit perspective, generics are the “rotten egg” and branded versions of the same drug are the “golden egg”. All of this highlights the concerns about how IRA Medicare fair prices may go terribly astray. The natural play for both PBMs and 340B covered entities in the face of MFPs is to move patients from those drugs to high list/high rebate alternatives. Two rowers rowing in unison. At the last 340B Health conference I attended, I heard multiple 340B representatives say, quite openly, that switching patients from MFP drugs to high list/high rebate alternatives was, in fact, their “game plan”. Ugh. #lifescienses #biotech #genericdrugs #pharmacies #pharmacy #pharmacists #PBM #PBMs #managedcare #coveredentities #formularies #formulary #UM #pharmaceuticals #drugs #medications #meds #IRA #InflationReductionAct #Medicare #PartD #MedicareAdvantage #generics #biosimilars #biosims Health Resources and Services Administration (HRSAgov), HHS Centers for Medicare & Medicaid Services U.S. Department of Health and Human Services (HHS) #oig #doj

Saving today, paying tomorrow? Imagine a world where saving on prescription drugs isn't the financial relief it promises to be. Welcome to the paradox of Pharmacy Benefit Management (PBM). PBMs were designed to negotiate lower drug prices. But here's the twist - these savings might not always trickle down to you. Instead, complex rebate systems and secretive contracts can obscure true drug costs, sometimes making medications more expensive for the end consumer. Ever wonder why your prescription costs fluctuate? Or why a drug suddenly becomes 'preferred' over another? The answers often lie within the intricate dance between PBMs, pharmacies, and insurers. This system, intended to save money, can inadvertently inflate the very costs it seeks to reduce. The real kicker? While your pocketbook feels the pinch, the overall healthcare expenditure climbs, driven by opaque pricing structures and incentives that don't always align with patient health outcomes. So, what's the solution? Transparency. It's time for a clear view into how drug prices are set and where our healthcare dollars are going. Only with this insight can we hope to unravel the paradox and ensure that saving on drugs doesn't end up costing us more in the long run. Let's start the conversation. Share your experiences and thoughts on how we can demystify pharmacy benefit management for the betterment of all.

In the midst of skyrocketing prices, nearly half of U.S. states have established or have pending legislation to create prescription drug affordability boards to cap or limit prescription costs for consumers and insurers. The federal government could help move the process along. Under the Medicare Drug Price Negotiation Program, the U.S. Secretary of Health and Human Services is negotiating with drug manufacturers to lower prices for certain medications. Officials have selected 10 medications for cost reduction under Medicare Part D, which is slated to go into effect starting in 2026. The resulting drug prices could be in important data point for state prescription boards as they undergo cost review and cost reduction efforts, one expert says.

The Federal Trade Commission (FTC) is preparing to sue the three largest pharmacy benefit managers (PBMs) in the United States: CVS' Caremark, Cigna's Express Scripts, and UnitedHealth's Optum Rx. The lawsuits will focus on these PBMs' business practices related to drug price negotiations, particularly for insulin. This action follows the FTC's interim report on its investigation into PBMs, which found that these companies use their market power to profit at the expense of patients and independent pharmacists. The three PBMs in question handle nearly 80% of all prescriptions in the U.S., raising concerns about market consolidation. PBMs claim to save people money on medications by negotiating rebates with drugmakers. However, critics argue that their practices contribute to rising drug costs in the U.S., with research suggesting that PBMs' opaque business models may be a factor. The impending lawsuits are part of broader efforts to address high drug prices in the U.S., as nearly one-third of Americans reported delaying or skipping medication doses last year due to costs. https://lnkd.in/e_xrnAuc #healthcare #HealthcareCosts #BigPharma #PBMs #FTC

Pharmacy benefits managers (PBMs)- third party administrators of prescription drug programs- have gained scrutiny in the US over the years. Independant pharmacies raised the alarm about "unfair" tactics used by PBMs to monopolize the industry, such as underpaying for prescriptions that are filled and claw-backs to reimbursements which threaten to put them out of business. The FTC announced plans this week to sue three of the largest PBMs over practices that they allege contribute to inflated drug prices. The PBMs targeted controlled 79% of US pharmacy benefit management in 2022 (according to the data platform Statista) when the initial investigation began : -Caremark (CVS Health) - 33% -Express Scripts (Cigna) - 24% -Optum RX (United Healthcare Group) - 22% The call for more transparency into their operations comes as PBMs blame manufacturers for higher drug prices and drug manufacturers justify increases blaming their higher list prices on rebating and fees collected by the PBMs.

🏹 Humira Biosims: Hitting the target or not? Finance says; “The concern with these ‘co-manufacturing’ agreements is that they are a veiled attempt by PBMs to control additional parts of the supply chain which has resulted in additional harm to consumers in the form of fewer drug choices and higher drug costs,” But wait what about BCBS of CA is doing as it shakes off its lethargy on a drug it spends a $100M a year? “For its new Humira pipeline, Blue Shield struck the deal through a company called Evio Pharmacy Solutions, which is owned by them and other Blue-branded health plans. Unlike a PBM, Blue Shield of California pays Evio a flat fee to negotiate with drug manufacturers rather than a fee based on the drug’s price. A division of German manufacturer Fresenius SE is making the drug for the insurer.” See Modern Healthcare link below This may be the better way to put pressure on the private label arrangements. Good job Fresenius! We need more of this in Medicare! #Humira #biosimilars