Restricting High Price Drugs - A Dangerous Trend? Save

Who makes billions in profits and millions in bonus monies?

Modern-day health insurers and their partnered pharmacy benefit managers (PBMs), that’s who.

Complicit in their efforts to establish greater profits in the name of better healthcare, both are reshaping their policies to restrict access to newer expensive drugs.

United Healthcare announced yesterday they intend to cut access to certain expensive and popular forms of insulin. In their realigning tiered therapies, they (and CVS Health) have removed the expensive and popular Lantus product and replaced it with a Lantus biosimilar as Tier 1 therapy, while moving Levemir from Tier 1 to Tier 2. (Citation source http://buff.ly/2dipIfu)

Serving the concerns of insurers and employers that expensive new specialty drugs (e.g., Humira and Enbrel) are becoming costlier, Express Scripts is now recommending that insurers and employers should cover fewer expensive drugs for many common indications, including inflammatory conditions like rheumatoid arthritis (RA) and psoriatic arthritis.

They claim such restrictions will force drug companies to compete and lower their prices.

But there is little evidence that this is so.

It seems far more likely that this scheme will limit the available “choices” of new therapies to the few companies and products able to compete with high dollar rebates (back to the PBM), ensuring that drug's place in a Tiered benefits system while the remaining expensive drugs (i.e. biologics) will be removed as a choice altogether.

Given there are 14 biologics in the rheumatology space – it seems likely there will be a few winners and many losers if ESI recommendations are accepted.

This is the latest effort by insurers and drug benefit managers to manage drug cost by restricting access. Heretofore, PBMs restricted access via tiered drug programs, prior authorizations, pathetic inefficient appeals processes and customer support services that are frankly irritating and worthless to the point of deterring the efforts necessary to provide better medicines and medical care.

Gone are the days of “choice”, when patients are offered all the FDA approved drugs for their disease indication. For many patients and prescribers, the potential list of 9 biologics for RA alone are practically limited to 2-5 biologics, with the remaining being nearly off limits given the inherent hassles and obstacles employed to deter alternative biologic use in favor of those highly rebated biologics.

The rebate system has become the seamy underbelly of specialty drug marketing. I would guestimate that most of the billions in profits and millions in bonuses are funded by the rebate game PBMs force the drug companies to play.

I know of companies who offered to lower the cost of their biologic in an effort to compete with the big name drugs, but were laughed away from the bargaining table by the PBMs who claimed that lower drug pricing does not benefit the PBMs and insurers. Instead they recommended the negotiating company increase (not decrease) its drugs price and then offer a greater rebate to the PBM. Then they may have a chance of competing.

Even worse are the insurer efforts to increase the out of pocket costs to the patient with higher premiums and copays while the insurers are making record profits.

Patient advocacy groups and U.S. physicians will undoubtedly cry foul over these new restrictions and voice grave concerns over the loss of options. You may or may not be bothered by fewer choices or prescribing limitations designed to limit costs. After all, such restrictions are in place worldwide and are proven to save money. However, we should be alarmed that the “choices” afforded are established by those who will benefit most – the PBMs and insurers.

Two wrongs don’t make a right; unless you’re the two who will benefit most – the PBMs (i.e., Express Scripts) and health insurers (i.e., United Healthcare).

“Choice” ain’t what it use to be.