CBF Launches Online Resource Examining Pharmacy Benefit Manager Practices

In light of rising health care costs, the role of Pharmacy Benefit Managers (PBMs) is being reviewed by policymakers, employers, patient advocates and healthcare stakeholders due to patients out of pocket costs of prescription drug costs. Recently, the California Biotechnology Foundation launched an online resource that tracks the latest reports, data and news related to PBMs.

PBMs are companies that manage prescription drug benefits on behalf of health insurers, Medicare Part D drug plans, large employers, and other payers. PBMs wield significant influence over prescription drug pricing, formulary decisions, and patient access to medications. By negotiating discounts with drug manufacturers and determining which medications are covered, PBM decisions directly impact patients’ out-of-pocket costs and overall healthcare experience. PBMs operate in the middle of the distribution chain for prescription drugs, using their purchasing power to negotiate rebates and discounts from drug manufacturers by:

• developing and maintaining lists, or formularies, of covered medications on behalf of health insurers,
• influencing which drugs individuals are able to access and use and determine patients’ out-of-pocket costs

For years, businesses and their health plans have enlisted the help of PBMs to control drug spending by utilizing the PBM central role in the drug-supply and payment system.

Today, the largest PBMs—UnitedHealth’s Optum Rx, CVS Health’s CVS Caremark and Cigna’s Express Scripts—process 80% of prescription claims, according to the Drug Channels Institute. Because the PBM market is so highly concentrated, drug manufacturers face high stakes when negotiating for formulary placement, including being completely left off the formulary. Offering high rebates is an important leverage that manufacturers use to reduce the chance of being excluded from a formulary and making their treatment inaccessible to patients. Often PBM formularies favor drugs that offer higher rebates over similar drugs with lower net costs and lower rebates. More often than not, those savings are pocketed by the PBMs and the insurance companies that own them, and not passed on to patients in the form of lower out of pocket costs.

As the state and national discussion about PBMs continues, it will be important to engage in a balanced discussion about the issue. Visit CBF’s website for more information about PBMs.

FDA Approves New Treatment for Alzheimer’s Disease

Promising news in the fight against Alzheimer’s disease (AD). This month, the federal Food and Drug Administration (FDA) gave full approval for a new Alzheimer’s disease treatment by Eli Lilly, donanemab-azbt (under the brand name Kisunla), which was proven to slow the cognitive decline in people with the disease by 35 percent during clinical trials.

Alzheimer’s disease is just one of the diseases that causes dementia. It affects 6.7 million people in the United States and is expected to affect 12.7 million people by 2050, according to the Alzheimer’s Association. A report released by the organization confirms over 720,000 Californians currently live with Alzheimer’s disease. That number will increase to 840,000 by the year 2025.

While the specific causes of Alzheimer’s are not fully known, it is characterized by changes in the brain—including amyloid beta plaques and neurofibrillary tangles—that result in loss of neurons and their connections. These changes affect a person’s ability to remember, think and speak.

Kisunla can help the body remove the excessive buildup of amyloid plaques and slow the decline that may diminish people’s ability to remember new information, important dates, and appointments; plan and organize; make meals; use household items; manage finances; and be left alone.

Kisunla joins only a handful of other therapies currently approved to treat Alzheimer’s. Visit the FDA for more information about Kisunla.