JustCare

Category: Drugs and technology

  • Some Medicare prescription drug plans dropping insulin coverage

    Some Medicare prescription drug plans dropping insulin coverage

    One of the many design and structural defects of the Medicare Part D prescription drug benefit is that the health insurers offering coverage have enormous latitude to determine the drugs they will cover. Not only does that mean the insurers might not cover some basic generic drugs, it means that they might cover some drugs today and different drugs tomorrow. With a recent legal requirement that limits out-of-pocket costs for people with Medicare using insulin, Medora Lee reports for USA Today that some Part D prescription drug plans are dropping coverage of insulin.

    Because insurers cannot charge people with diabetes more than $35 a month for each insulin product they take, Part D insurers might be able to keep down premiums and attract healthier members by dropping insulin coverage. The insurers also might project greater profits if they do not cover certain insulin products. So, anyone with Medicare in need of insulin better beware.

    You should check to ensure that your Part D prescription drug coverage will pay for the insulin you take in 2024. If not, you should switch to a different Part D plan if you can. Keep in mind that your Part D plan can change the drugs it covers at any time. However, if it does, you generally have a right to coverage of your medically necessary drug throughout the rest of the year if you have no alternative.

    It’s a travesty that Part D  insurers can game the Medicare system to the detriment of people with diabetes. It’s equally problematic that they can game the system to hurt people with all different sorts of prescription drug needs. For example, CVS was found not to have generic versions of some drugs on its Part D formulary; it profited more from only having the brand-name drugs, for which it received rebates and otherwise benefited financially.

    It’s also deeply concerning that Part D insurers can charge higher copays for some drugs than Costco charges for the full cost of the same drugs. One Just Care reader reported that to keep his costs down, he had to get his drugs from different sources.  Costco had lower prices for some drugs and his Part D plan had lower costs for others.

    In 2025, people with Part D will not pay more than $2,000 out of pocket for drugs their insurer covers. That’s the good news. I’m willing to bet that the Part D insurers find a way to take advantage of this new consumer protection, while making it harder for their members to get the drugs they need.

    Congress should come to its senses and establish one prescription drug benefit that meets everyone’s needs. It should not allow Part D plans to meet only some prescription drug needs. Right now, the Medicare Part D benefit is designed to line the pockets of insurance companies and pharmacy benefit managers not to bring down drug costs as much as possible for people with Medicare or to ensure that their Part D coverage meets their current and future prescription needs.

    Here’s more from Just Care:

  • Drug prices: Biden v. Trump

    Drug prices: Biden v. Trump

    Heather Landi reports for Fierce Healthcare on how Donald Trump’s former Secretary of Health and Human Services, Alex Azar, and Joe Biden’s current Secretary of Health and Human Services (HHS), Xavier Becerra, would address high drug prices. Not surprisingly, their views differ significantly.

    Azar does not recognize that pharmaceutical companies in the US engage in price fixing. Or, that the pharmaceutical companies often delay the release of new drugs in order to maximize profits on older drugs, hampering innovation. Or, that it’s much easier for people in France to fill their prescriptions than people in the United States because out-of-pocket costs in the US are so high.

    Azar does recognize the power of pharmacy benefit managers, PBMs, to drive up people’s out-of-pocket costs, but does not suggest a plan to fix that issue,. For example, he does not propose removing PBMs from the process of deciding which drugs are covered and at what price to patients.

    Last year, Congress passed the Inflation Reduction Act or IRA, giving Medicare drug price negotiating power for 10 drugs in 2025; the Centers for Medicare and Medicaid Services have chosent the 10 drugs, based on which cost the Medicare program the most. The IRA also capped out-of-pocket costs for each insulin product people with diabetes use at $35 a month. And, it imposed an out-of-pocket limit of $2,000 for drugs covered by Medicare Part D plans beginning in 2025.

    President Joe Biden’s HHS Secretary Becerra touts Medicare’s drug price negotiation power as an effective way to lower drug costs, pointing out that the IRA now caps the cost of insulin at $35 per month for seniors who have Medicare.

    Of note, the Trump administration had proposed that Part B drug prices–for inpatient drugs–be tied to prices paid abroad for these drugs. That sounds to me as if it would have been a smart move. But, the Biden administration rescinded that proposal, likely under pressure from the pharmaceutical industry.

    Here’s more from Just Care:

  • The cost of weight-loss drugs is driving up our insurance premiums

    The cost of weight-loss drugs is driving up our insurance premiums

    Gina Kolata reports for The New York Times that the cost of weight-loss drugs is not what it seems. People must take them throughout their lives, and weight-loss drugs have list prices of as much as $1,300 every four weeks. Ozempic, Wegovy and drugs like them could literally mean a huge increase in people’s health insurance premiums.

    One epidemiologist projects that if prices for these weight-loss drugs are not controlled, they could increase health care spending by 50 percent! What’s interesting is that it is not only the drug manufacturers that are raking in the profits from these drugs. The health insurance companies and pharmacy benefit managers are profiting wildly from them as well.

    The weight-loss drug manufacturers pump up the list price of the drug so that they can then give a major rebate to the pharmacy benefit managers and insurers as a financial incentive to promote and cover them. The insurers and PBMs pocket these rebates or most of the rebates rather than pass them along to consumers.

    Net prices for the weight-loss drugs are, according to the conservative American Enterprise Institute, AEI, much less than the list prices. The AEI believes that the net price for Ozempic is just $300, $650 less than its list price. Similarly, AEI believes the net price for Wegovy is $700 or $650 less than its list price.

    The weight-loss drugs are unaffordable to many Americans because they cannot afford the copays even with insurance, they have no health insurance, or their insurance does not cover them. Medicare does not cover weight-loss drugs for weight-loss. However, it does cover the drugs for people with diabetes. Medicaid rarely covers the drugs.

    Novo Nordisk, a Danish company, expects to generate $11 billion in revenue this year from Ozempic and another $4 billion from Wegovy. Some might argue that the price for these drugs is fair because treating obesity, with its risk of diabetes, kidney failure, heart attacks and strokes, can be very expensive. No other wealthy country pays prices anywhere near as high as Americans.

    Here’s more from Just Care:

  • Pharmacies sue pharmacy benefits manager for overcharging them

    Pharmacies sue pharmacy benefits manager for overcharging them

    In a health care world in which, among other things, the government is now overpaying insurers offering Medicare Advantage plans $140 billion this year without seeming to blink, pharmaceutical companies are charging tens of thousands of dollars for some life-saving medicines with no government talk of across-the-board drug price negotiation, and hospital systems are dying because Medicare Advantage plans are not paying their bills, it’s refreshing to learn that pharmacies are fighting back against overcharges. Reuters reports that pharmacies are suing Express Scripts, a pharmacy benefits manager (PBM), in a class action for raising fees on them and reimbursing them at low rates.

    Express Scripts is a company that rakes in billions in profits a year for Cigna from pharmaceutical company rebates it receives for putting high cost drugs on insurance company formularies–the prescription drugs your insurance covers–and steering patients to use them. No kidding. For example, you can read here about how pharmacy benefit managers (PBMs) are getting paid big bucks from Humira’s manufacturer to steer people away from its lower-cost competitors.

    Because the pharmacy benefit managers, often in collaboration with your insurance company, are looking to maximize their profits, you could end up spending more if you get your drugs through your insurance company rather than through Costco mail-order, MarK Cuban’s Cost Plus Pharmacy or a coupon at your local pharmacy. This is true if you have a Medicare Part D prescription drug plan as well. Always check with Costco or another low-cost mail order pharmacy to save money; if that’s not an option, ask your pharmacist whether there’s a less costly option than using your insurance to cover your drugs; there often is.

    Because the pharmacies have the will and the money to take on Express Scripts, they should be able to correct the problem and end the gouging. If only the government would step in on behalf of individuals to keep the pharmacy benefit managers from gouging us.

    The complaint by four pharmaceutical companies accuses Express Scripts of collaborating with Prime Therapeutics to hike up reimbursement rates and fees.

    Here’s more from Just Care:

  • Want your prescription drugs quickly? Get drone delivery

    Want your prescription drugs quickly? Get drone delivery

    Bruce Japsen writes for Forbes on drone delivery of prescription drugs. If you happen to live in certain cities, you can now have your prescriptions dropped  outside your door within an hour of your request to fill them, at no extra cost. Several companies are testing drone delivery service in various cities across the US.

    Amazon’s Prime Air drone will deliver the prescription drugs in College Station, Texas. Over time, residents of other cities will be able to receive fast drone deliveries of their prescriptions through Amazon. But, it could take a few years. Prime Air drones already operate in College Station and Lockeford, California.

    Amazon’s press release reports that “Eligible Amazon Pharmacy customers can select ‘free drone delivery in less than 60 minutes’ at checkout. A pharmacist will then ensure medications are loaded and transported to a customer’s home within the next hour. College Station residents selecting drone delivery will have access to more than 500 medications that treat common conditions, including flu, asthma, and pneumonia.”

    Walgreens, CVS Health and Walmart are already testing drone delivery of prescription drugs. Walgreen’s is using Wing’s drones to deliver prescription drugs as well as over-the-counter health and wellness products to tens of thousands of people in the City of Frisco and the Town of Little Elm.

    CVS Health was testing drone deliveries of prescription drugs as far back as April 202o in The Villages in Florida. It partnered with UPS to make these deliveries to about 130,000 people. But, since the initial launch, there is no information as to whether the drone delivery service is working or has been expanded.

    Walmart began working with DroneUp to deliver medicines and other products to about 4 million of its customers back in May 2022. For $3.99, it delivers up to 10 pounds of items in as little as 3o minutes in parts of Arizona, Arkansas, Florida, Texas, Utah and Virginia.

    The corporations say drone delivery of medicines is about helping people to adhere to their medication regimens. One in three people don’t fill their prescriptions. While some can’t get to the pharmacy, for which drone delivery should help, a lot of failure to adhere to drug regimens is about not being able to afford the prescription drug copays. Of course, when that’s the case, people will need more than drone delivery service to comply with their medication regimens.

  • Importing drugs from abroad should be legal

    Importing drugs from abroad should be legal

    In a new paper, Stephen Salant, a professor at the University of Michigan, makes a compelling case that people in the US should be able to import drugs from abroad and that it is safe to do so.

    Salant explains that people in the US spend much more than people in other wealthy countries for the identical brand-name drugs. Drug prices are lower in other wealthy countries because their governments negotiate with drug manufacturers. The lower prices abroad are still a lot higher than the cost of producing the drugs. And, drug manufacturers invest millions to sway Americans to believe that it’s unsafe to import drugs from abroad.

    We typically pay three and a half times more for a brand-name drug than people in other countries. Most other wealthy countries use price controls to keep prescription drug prices down. They either value a drug based on its cost-effectiveness. Or, they use reference pricing to bring drug prices down.

    Other countries still pay prices than can be as much as 100 times more than the cost of producing drugs. Western Europeans pay a minimum of $40,000 for a 12-week course of Sovaldi to treat hepatitis C. But, Sovaldi costs its manufacturer $68-$136 to produce that course of treatment.

    At the same time, Pharma relies on non-profit shill groups to argue that imported drugs could be counterfeit and unsafe and sway public opinion. Consumer protection is a pretext, an argument to keep drug prices high and generate enormous profits for drug companies. Pharma hired former FBI Director Louis Freeh’s firm to say that importing drugs would “open a new, unregulated pipeline into the United States.” But, at the time, 16 states simply were proposing to import drugs from highly regulated prescription drug markets abroad.

    People can already buy drugs from abroad when they travel abroad, as well as online. And, big retail outlets like Amazon and Costco theoretically could bulk purchase drugs from abroad safely and sell directly to people in the US. All the evidence suggests that these drugs are as safe as drugs people buy in the US.

    Here’s the truth: “The FDA has never reported a death or adverse reaction suffered by any patient in the U.S. who has personally filled his valid prescription online or in person from a pharmacy licensed in another high-income country.” The government has never prosecuted people in the US for importing drugs for personal use, even though it is illegal. But, the government does take action against companies that try to buy drugs abroad for resale in the US.

    “Asking sick people to finance drug innovation, which is of value not only at home but abroad, is ethically indefensible,” argues Salant. “The burden falls heaviest on sick Americans since our prices are by far the highest. People currently in good health should shoulder more of the burden. Increased subsidization, financed by general taxes at home and abroad is, in my view, a step in the right direction.”

    Here’s more from Just Care:

  • Coronavirus: Should you get the 2023 booster shot?

    Coronavirus: Should you get the 2023 booster shot?

    The next Covid-19 booster shot should now be available from your local pharmacy, health clinic or doctor’s office. Medicare pays for it in full, whether you are enrolled in Traditional Medicare or a Medicare Advantage plan. If you are in a Medicare Advantage plan, the booster shot should be covered in full from network pharmacies, but perhaps not if you go out of network for the booster. Should you get the booster shot?

    The Food and Drug Administration just approved the booster as safe and effective. The booster shot protects people from the current Covid 19 variants in the US. The Centers for Disease Control panel of advisors believes that everyone over six months old should get it. Some argue that if only older adults are vaccinated, it will mean 100,000 additional hospitalizations.

    Fewer than one in five Americans got the Covid-19 booster that was approved in 2022. But, the data show that people who got the booster had a much lower likelihood of getting very sick or dying.

    Many people are getting Covid-19 now and more people are being hospitalized for it than earlier in the summer. More still are expected to be hospitalized this fall and winter.

    The list price of the booster is $130. But Medicare pays for it under Part B. Medicaid also covers it. And, so does commercial insurance. If you are uninsured, the federal government’s Bridge Access Program covers the vaccine at Federally Qualified Health Centers and at Walgreens, CVS and some other pharmacies.

    While the booster shot might only keep people from getting Covid for a few months, it still reduces the likelihood of being hospitalized and dying for a much longer period of time.

    The booster was tested on monkeys and mice, not people. But, around the world, billions of people have gotten the booster safely.

    Should you get the booster shot? You probably should not get the booster shot if you’ve had Covid in the last two months. Otherwise, many recommend you get the booster shot soon. If you are planning to travel over the winter holidays, you might wait until early November to get the booster. You then increase the likelihood that the vaccine protects you from infection during your travels.

    Some doctors question the value of the booster for people who have had Covid-19 and have been vaccinated one or more times. They believe that this alone should keep them from getting seriously ill from Covid-19, even if they get Covid.

    Should you get the Covid booster, the RSV vaccine and the flu shot at the same time? It might be smart to space them out.

    Free Covid tests: The federal government is once again offering free Covid tests beginning September 25. Click here to get four free tests sent to your home.

    Here’s more from Just Care:

  • Insurers promote Humira over lower cost alternatives

    Insurers promote Humira over lower cost alternatives

    Humira, which treats rheumatoid arthritis and costs a small fortune, is a blockbuster drug that millions of Americans depend on. Fortunately, there are now far lower-cost biosimilar alternatives. Arthur Allen reports for Kaiser Health News that health insurers and the drug company middlemen they work with have no interest, and everything to gain, from not promoting biosimilars, needlessly costing our health care system hundreds of millions of dollars a year.

    Humira is a biologic, made with living cells, with a list price of $6,600 a month, while biosimilars cost just under $1,000 a month. So, if the prescription drug marketplace worked, most everyone would be taking the biosimilar. But, the Pharmacy Benefit Managers or PBMs, who are responsible for designing insurer formularies– the list of prescription drugs an insurer covers and at what copay–have a financial interest in continuing to steer people to Humira, as do the insurers.

    Even though Humira’s list price has increased six-fold since it was first launched in 2003, the PBMs make money offering it, as do the health insurers. The PBMs receive rebates from Humira’s manufacturer, AbbVie, for promoting the drug and share the rebate with the insurers. The only people who lose are the insureds.

    If 313,000 people who take Humira instead took a biosimilar, the equivalent of a generic version, our health care system could spend about $9 billion less. But, companies manufacturing the Humira biosimilar can’t afford to give PBMs big rebates. So, the PBMs are less interested in promoting their drugs.

    Other wealthy nations don’t have PBM middlemen and therefore don’t deal with these gross financial incentives that drive up health care costs. In other countries, almost everyone has switched to a Humira biosimilar. With the profit motive driving insurers and PBMs in the US, however, it’s not clear whether companies manufacturing biosimilars can survive here.

    It costs about $200 million to develop a biosimilar. Without substantial sales, it’s not worth the effort. Unless Express Scripts, Optum Rx, and CVS Caremark three large PBMs, reduce the copay for the Humira biosimilar so that it’s less than the copay for Humira, doctors are not likely to prescribe the biosimilar, and the PBMs will kill the biosimilar market.

    What’s crazy is that the price of biologics continues to rise at a rate of 12.5 percent a year over the last five years, and it is not affecting the market for them, even when there are biosimilars.

    Allen reports that AbbVie is telling health insurers that, if they promote biosimilars over Humira, AbbvVie will cut the rebates it pays them for Humira and other drugs it manufacturers. AbbVie also reportedly increased rebates to PBMs for Humira.

    To be clear, even though patients might have the same copay for Humira as for a biosimilar, their health insurance premiums are significantly higher because people take Humira and not a biosimilar. Humira costs more. Moving to the biosimilar would reduce health care spending and make health care more affordable, helping to ensure people get needed care.

    Even with Medicare, the annual copay for Humira can be as high as $8,000.

    Doctors don’t steer their Humira patients to biosimilars as they tend not to want to switch their patients off medications that work. Even though the biosimilars appear to be as effective as Humira, if patients aren’t saving money by switching off Humira, they have no interest in messing with their drug regimens.

    Small PBMs and insurers who don’t make their money off of drug rebates, such as Prescryptive and Kaiser Permanente, have moved most of their patients to biosimilars, saving their patients money. Prescryptive says that switches to biosimilars have happened “with absolutely no interruption of therapy, no complaints, and no changes.”

    Here’s more from Just Care:

  • Psilocybin found to relieve depression for extended period

    Psilocybin found to relieve depression for extended period

    A small amount of psilocybin can relieve depression for an extended period, according to a new study published in JAMA. Annalisa Merelli reports in Stat News that psilocybin could be a promising treatment for people suffering from depression, for whom antidepressants and psychiatric counseling are not helpful.

    Earlier research had found that psilocybin, found in some mushrooms, can lead to fast improvements in people’s mental health. This new study looks at the effects of a small dose of psilocybin on people with major depressive disorder as long as six weeks after taking one dose of the drug. The findings strongly suggest psilocybin, in combination with psychological support, can be used to treat major depression.

    Psilocybin apparently lets the brain be rewired, helping people let go of old beliefs and memories and allowing them to better handle their emotions.

    The researchers studied 104 people between the ages of 21 and 65, giving half of them psilocybin and the other half a placebo. They also looked at the safety of taking a 25 mg dose of psilocybin in their phase 2 trial. They studied participants over an 18-month period. And, all participants received psychotherapy before, during and after the trial.

    The researchers found clinically significant lessening of depressive symptoms and functional disability within eight days of receiving the psilocybin. They found no serious side effects. Trial participants did experience headaches, nausea and stomach aches.

    While psilocybin remains an illegal drug under federal law, some states are beginning to take a different view of some psychedelics for medicinal purposes. Colorado recently legalized medicinal psychedelics.

    Here’s more from Just Care:

  • Medicare names 10 drugs subject to price negotiation

    Medicare names 10 drugs subject to price negotiation

    It’s beyond even my imagination that Medicare’s ability to negotiate just 10 drug prices as a result of the Inflation Reduction Act is a big deal. There are more than 19,000 prescription drugs, and the IRA still leaves people with Medicare paying far more than people in other wealthy countries for these drugs–if they can afford to. But, in this crazy country, the pharmaceutical industry is so powerful, the Biden administration and its allies are celebrating this accomplishment and concerned that Pharma’s legal challenges could upend it.

    The Inflation Reduction Act gave Medicare the right to negotiate the prices of 10 brand-name drugs that have been on the market for some time and do not have generic competition, beginning in 2026. The goal is to save both Medicare and Medicare patients money. Unlike every other country, the US effectively confers monopoly pricing power to pharmaceutical corporations for their patented prescription drugs and, consequently, we pay higher prices for medications than every other wealthy country.

    Over the next four years, Medicare will have the right to negotiate prices for up to 60 prescription drugs, if the pharmaceutical industry does not prevail in its lawsuits to prevent the government from negotiating drug prices. After that, Medicare will be able to negotiate the price of up to 20 drugs each year. President Biden hopes that older adults will support his and other Democrats’ candidacies in 2024, as a result of, and to ensure the lasting benefits of, this achievement.

    In particular, millions of people with Medicare should see significant savings on several drugs that treat diabetes. In addition, beginning this year, diabetics with Medicare pay no more than $35 a month for each insulin drug they use. And, important vaccines, like RSV, are free. But, if voters don’t re-elect Democrats, it’s more than likely that a Republican Congress and President will try to undo these savings they refused to support.

    The $99 billion in projected savings from drug price negotiation over 10 years is going towards an annual out-of-pocket limit of $2,000 for prescription drugs under Medicare Part D.

    How will the drug price negotiations work? Pharmaceutical companies will need to agree to negotiate the prices for their drugs on the government’s list of 10. If they agree, the pharmaceutical companies must share data with the government to be used in negotiating the price. If they do not agree to drug price negotiation, they will pay a large penalty tax that can be as high as 95 percent of their sales of that drug, or they could withdraw the drug from the Medicare and Medicaid markets.

    In February 2024, the government will propose a price for each drug. The pharmaceutical companies can propose an alternative.  Negotiations will ensue. The government will announce final prices in September 2024, but the negotiated prices will not take effect until January 2026.

    In February 2025, the government will announce the next 15 drugs to have their prices negotiated.

    The drugs subject to price negotiation fall into two buckets, explains Dylan Scott for Vox:

    1)  Seven expensive drugs for diabetes, heart disease and other chronic conditions that millions of people use:

    • Eliquis, for blood clots ($561 list price for one month’s worth of treatment that cost Medicare around $16.5 billion over the year ending May 2023)
    • Entresto, for heart failure ($545 list price)
    • Farxiga, for diabetes, heart disease, and chronic kidney disease ($549 list price)
    • Januvia, for diabetes ($586 list price)
    • Jardiance, for diabetes and heart failure ($570 list price)
    • Xarelto, for  blood clots and heart disease ($542 list price)
    • Insulin injectors and the products used to refill them: Fiasp, Fiasp FlexTouch, Fiasp PenFill, NovoLog, NovoLog FlexPen and NovoLog PenFill

    2) Three extremely expensive drugs that tens of thousands of people with severe and sometimes life-threatening conditions use and that cost Medicare about $2.6 billion each over the year ending May 2022:

    • Enbrel, for rheumatoid arthritis, psoriasis, and psoriatic arthritis ($1,762 list price for one week’s dosage)
    • Imbruvica, for blood cancers ($13,546 list price for one month’s worth of tablets)
    • Stelara, for psoriasis, psoriatic arthritis, Crohn’s disease, and inflammatory bowel disease ($25,497 list price for eight weeks of use) 

    Here’s more from Just Care: