PBMs and insurers are getting rolled into single entities with clout over the supply chain and benefit design. Any major changes in how they operate may wait as they spend 2019 figuring out how to mesh.
We’ll see what happens to the administration’s Part B proposal. Congress is not likely to take bold action, partly because drugmakers are a strong influence on both parties. That leaves the FDA and Administrator Scott Gottlieb, MD, as major players in efforts to rein in drug prices.
The PBM unit of the health giant CVS decided that any new drug exceeding $100,000 per quality-adjusted life year (QALY) may be excluded from the formularies that are maintained by its clients. Patient groups (with the backing of pharma) say that the measure is discriminatory.
Pharma and Trump administration officials decry them as backroom deals. But payers and PBMs say rebates are an important negotiating tool with drugmakers. Take it away and drug expenditure will go up even faster.