No longer mere middlemen, these major players’ ability to influence pharmaceutical prices keeps growing along with the number of covered lives they represent. That doesn’t necessarily translate into savings for health insurers, but it sure can. Some plans want PBMs to create pre-certification requirements for specialty drugs.
Over the past 18 months, formulary exclusion has gone from being a targeted tactic to a commonly used PBM weapon. The drugs kept out are often nonpreferred agents with low utilization, but for the first time a couple of specialty drugs are also on the outs.
In a wide-ranging Q&A, Steve Miller, MD, the CMO at Express Scripts, explains why he took the controversial stand again Gilead’s Sovaldi, and how he plans to further gain a handle on drug prices. For instance, “I’ve been advocating for biosimilars very aggressively over the last eight years.”
The second largest consumer oriented and operated plan in the country dies, and more could follow. Critics say that’s what comes of trying to make something out of nothing, as co-ops are a creation of the ACA. Proponents say there’s still hope.
Screening rates for the deadliest of cancers have languished, but recent rulings by CMS and the U.S. Preventive Services Task Force mean nearly universal coverage for low-dose CT scans. The cost-effectiveness of this effort for payers will depend on skillful implementation.
You can put a price tag on a good night’s sleep. Patients are willing to pay nearly $67 for a product that improves sleep onset latency by 10 minutes, reduces wake time after sleep onset by 15 minutes, and improves total sleep time by one hour.