JustCare

Tag: CVS

  • Why do people pay so much for Humira now that it’s off-patent?

    Why do people pay so much for Humira now that it’s off-patent?

    Humira, the exorbitantly priced drug taken by millions of Americans, finally lost its patent at the end of 2022, five years later than in Europe. But, even though biosimilar drugs are available, people’s out of pocket drug costs for this drug continued to be high. The drug rebate system in the US benefits drug middlemen and insurers and hurts patients, reports Joshua P. Cohen for Forbes.

    In short, pharmacy benefit managers (PBMs) make a fortune negotiating drug discounts from manufacturers. They usually see these discounts in the form of rebates, which they can pocket and/or share with the insurers offering prescription drug coverage. Americans rarely see the benefits of these rebates.

    Moreover, PBMs, which determine which drugs an insurer covers on its formulary and at what copay, can opt not to include drugs on the formulary. So, Humira’s manufacturer, AbbVie gave PBMs a huge rebate to include Humira on their formularies. The PBMs could then opt not to include biosimilar equivalents on their formularies or to make the biosimilars more expensive to enrollees, in order to maximize profits.

    That appears to be what’s happening. PBMs are not making it easy and inexpensive for people to get a biosimilar drug, even though there are more than ten of them available on the market. These biosimilars had only two percent of market share last March, after being available for 15 months.

    Now, more people are taking a biosimilar of Humira. The big PBMs are finally offering biosimilars. But, CVS and Express Scripts, two PBMs, are doing so with a biosimilar from which they receive a co-branded licensing fee and discounts, in order to continue to maximize their profits from the drug. They steer their customers to their biosimilars, which are often more costly than others.

    What you can do? Shop around. Check out Mark Cuban’s Cost Plus Drugs, Costco and other sources for a lower-cost biosimilar.

    Here’s more from Just Care:

  • Insurers end agent commissions for certain Medicare Advantage plans

    Insurers end agent commissions for certain Medicare Advantage plans

    CVS and Elevance appear to believe that some of their Medicare Advantage plans are less profitable than others. To maximize profits, they have ended commissions to insurance agents for certain Medicare Advantage plans, reports Allison Bell for ThinkAdvisor. Bottom line, if you live in a state where insurer agents don’t have a financial incentives to steer you to those Medicare Advantage plans, you have even more reason not to trust an insurance agent to help you choose a Medicare Advantage plan. Get free unbiased advice from your state health insurance assistance program.

    It seems that the less profitable Medicare Advantage plans are in California, Connecticut, New York and Texas. What does that mean for consumers? Most likely, insurance agents will not advise them to sign up for certain Medicare Advantage plans even though those plans could be better options for them. Of course, one never knows.

    Right now, during the Medicare Open Enrollment Period, people are choosing between traditional Medicare and Medicare Advantage plans. If you can afford traditional Medicare’s upfront costs–the cost of Medicare supplemental coverage–or you have Medicaid or retiree coverage, enroll in traditional Medicare to ensure you will be covered for the care you need from the physicians and hospitals you trust, in a timely manner. If you cannot afford the cost of supplemental coverage and you need costly care, you will be taking a gamble choosing a Medicare Advantage plan.

    Most people with Medicare can still choose a Medicare Advantage plan that does not charge a monthly premium. And most will also have coverage for some dental benefits. But, beware. With Medicare Advantage plans, you don’t pay upfront, but as soon as you get sick and need complex care, you often pay big time–they might not cover your care, they might not cover the cancer center of excellence you want to use, they might delay your care even though you need it urgently, and they might charge high out-of-pocket costs.

    The dental benefit offered in Medicare Advantage is often very limited. It can be hard to find a dentist near you who will accept coverage. You will still likely have high out-of-pocket costs.

    No matter what you do, if you are in a Medicare Advantage plan and not switching to traditional Medicare, look very carefully at changes to your current plan and other options. You won’t be able to see whether a Medicare Advantage plan has high rates of prior authorization or high denial and mortality rates, unfortunately. That’s what you really need to know.

    Also, keep in mind that the five-star Medicare Advantage plans are usually better than the 1, 2, 3 and 4-star plans on some metrics, but they can still have high denial rates and high mortality rates. You just can’t know.

    Some good news on the prescription drug front. Your Part D drug coverage, whether through a stand-alone plan if you have traditional Medicare or through a Medicare Advantage plan, will have a $2,000 out-of-pocket limit in 2025. Unfortunately, your premiums and deductibles might go up and the list of drugs covered could shrink. Take a hard look at your options on Medicare Compare, the government’s web site comparing your options.

    Centene’s WellCare division seems to have decided that its Part D drug plans are not profitable enough any longer so it has stopped paying brokers commissions to steer people to those plans.

    For free unbiased help making a Medicare choice, call your state health insurance assistance program or the Medicare Rights Center at 1-800-333-4114.

    Here’s more from Just Care:

  • UnitedHealth, CVS and Cigna helped fuel opioid crisis

    UnitedHealth, CVS and Cigna helped fuel opioid crisis

    [Editor’s note: I am reposting this piece because it brilliantly exposes how the drug middlemen “PBMs,” who are supposed to be delivering value to Americans, deliver value primarily to themselves and the insurers they work for. They push opioids to vulnerable Americans without prior authorization because they make hundreds of millions of dollars doing so, even when they know that these opioids are killing people.]

    A recent Barron’s exposé detailing pharmacy benefit managers’ (PBMs) backroom dealings in the opioid crisis should be read by everyone. PBMs, which most Americans encounter only indirectly through their health insurance plans, have quietly amassed enormous power over which medications we have access to — and how much they cost. This power extends not only to routine prescriptions but also, as it turns out, to some of the most devastating public health crises of our time.

    The report reveals that the largest PBMs — CVS Caremark, UnitedHealth’s Optum Rx, and Cigna’s Express Scripts — were heavily involved in the distribution of OxyContin, a drug at the center of the opioid epidemic. Between 2016 and 2017, these companies raked in more than $400 million in fees and rebates from Purdue Pharma, OxyContin’s manufacturer. That these rebates were essentially tied to the volume of opioids sold is not just alarming — it’s emblematic of how these middlemen prioritize profit over public health.

    The role of PBMs in drug pricing and availability has been contentious for years. The middlemen argue that their rebate system helps lower costs for employers and insurance plans, but this claim often falls apart under scrutiny. As Barron’s found, PBMs received as much as 19.75% in rebates from OxyContin sales, depending on the dosage and the number of pills prescribed. The higher the dosage, the bigger the rebate and profits. This system, which rewards higher utilization of a dangerous opioid, contradicts the PBMs’ – like CVS Caremark’s – own professed claims of fighting opioid abuse.

    For years, PBMs have presented themselves as crucial gatekeepers, using their clout to negotiate lower drug prices. But the reality, as the article highlights, is far murkier. PBMs, including CVS Caremark and Express Scripts, claim they pass the majority of rebates back to their clients — figures as high as 99%. Yet, these rebates are negotiated in secret, and consumers rarely see the benefits. The rebates often serve to maintain PBMs’ relationships with drugmakers, who want to secure prime placement on formularies — the list of drugs an insurance plan covers.

    The opioid crisis, as Barron’s demonstrates, could be a chilling preview of how PBM-driven rebate schemes might contribute to other drug pricing scandals. If PBMs have been willing to accept massive rebates from Purdue Pharma in exchange for keeping OxyContin widely available during a deadly opioid epidemic, what other drugs have been pushed to the forefront based on financial incentives rather than medical necessity or effectiveness?

    The documents that Barron’s obtained, many of which were previously confidential, show that PBMs had ample opportunity to stem the tide of opioid overprescribing. They could have placed stricter limitations on OxyContin or required prior authorization (which they make significant use of for medically necessary medications) to ensure that the drug was being prescribed appropriately. Instead, they allowed Purdue to maintain a stronghold on the market. According to memos, PBMs even demanded higher rebates as the opioid epidemic worsened.

    As the article suggests, this isn’t merely a historical issue. The opioid crisis may have peaked in the late 2010s, but its effects are still being felt today. And the practices of PBMs — opaque rebate deals, backroom negotiations and a relentless focus on profit — are still very much in place. While Purdue Pharma and its executives have been held accountable through legal settlements, PBMs have largely escaped similar consequences. The lawsuits against PBMs for their role in the opioid crisis are still ongoing, and CVS Caremark’s $5 billion settlement, finalized last year, didn’t even require an admission of wrongdoing.

    This begs a larger question about the pharmaceutical supply chain as a whole. If PBMs have the power to negotiate how drugs like OxyContin are covered, and if their decisions are driven by maximizing profits through rebates, can they really claim to be stewards of affordable health care? (Regular readers of this newsletter should roll their eyes at that question.)

    For too long, PBMs have operated with little transparency. As the Barron’s investigation shows, this secrecy has allowed them to profit handsomely from one of the deadliest public health crises in U.S. history. The opioid crisis could be the most egregious example of PBM malfeasance, but it’s far from the only one. As long as PBMs continue to operate without appropriate oversight, the American public will remain vulnerable to their influence over drug prices — and, by extension, their health.

    Here’s more from Just Care:

  • Humana and CVS will raise costs for Medicare Advantage enrollees in 2025

    Humana and CVS will raise costs for Medicare Advantage enrollees in 2025

    Humana and CVS intend to raise premiums and reduce benefits on their MA plans in 2025, reports Rebecca Pifer for Health Care Dive. They want to increase their profits further, even though the government already overpays them billions of dollars a year.

    As many as 700,000 CVS and Humana MA enrollees could switch to other plans, and CVS and Humana don’t seem to care. UnitedHealth is likely to grow its business in the process, depending upon whether it decides to cut benefits and/or raise premiums. The insurers offering Medicare Advantage are unlikely to increase their out-of-pocket caps and their deductibles, which people with Medicare apparently care most about.

    We won’t know what these insurers will decide to do until October. To be clear, CVS and Humana, like all of the big insurers, are first and foremost in the Medicare Advantage business to generate profits for their shareholders. Enrollee needs are secondary. They will exit markets where they don’t see good profits.

    CVS, Humana and UnitedHealth all own medical provider groups. So, they are likely to continue their MA businesses in counties in which those groups have clinics and they can generate better profits. 

    Insurers are most likely to raise copays for specialty care, which people can’t really wrap their heads around before enrolling and needing specialty care. Insurers also could cut supplemental benefits, such as money for home improvements and pet care.

    The insurers have a lot of discretion, but they can’t change anything they want. The government limits their ability to change “total beneficiary cost,” which is limited to $40 per enrollee each month. 

    Here’s more from Just Care:

  • CVS plans to raise Medicare Rx premiums a lot in 2025

    CVS plans to raise Medicare Rx premiums a lot in 2025

    In an op-ed for MarketWatch, Brett Arens’s Roi warns about rising Medicare Part D premiums.

    The CFO at CVS is alerting people that Medicare Part D premiums will increase significantly in 2025. How much of that increase amounts to more profits for CVS? It’s already profiting from pocketing pharmaceutical company rebates instead of passing them on to its Part D enrollees in the form of lower out-of-pocket costs.

    A series of articles over the last few years highlight tactics CVS uses to maximize profits. For example, it sometimes makes its Part D enrollees buy brand-name drugs, for which CVS earns more. So, it’s no surprise that CVS is planning another premium hike. Premiums will be “much, much higher” says Thomas Cowhey, the CFO.

    CVS knocked up Part D premiums 20 percent this past year. This time round, the higher premiums will allow CVS to protect its profits from rising costs resulting from the $2,000 out-of-pocket cap for Part D coverage that goes into effect in 2025.

    CVS believes that more people will be filling their prescriptions once Part D has a $2,000 out-of-pocket cap. Costs will no longer be a barrier for some, after they spend $2,000 out of pocket. The question then becomes how many people have $2,000 to spend to reach that out-of-pocket cap when they need to?

    As of now, about one in seven people with Medicare say they are not filling their prescriptions because of the cost.

    Some analysts believe that the new $2,000 out-of-pocket cap in Part D will steer more people into Medicare Advantage plans. Medicare Advantage plans almost always include prescription drug coverage in their premiums. Medicare Advantage plans are likely to look less expensive than Traditional Medicare, where people would have to buy a stand-alone Part D prescription drug plan.

    Here’s more from Just Care:

  • CVS profits from manufacturing its own generic drugs

    CVS profits from manufacturing its own generic drugs

    CVS has become the sixth largest corporation in America, owning not only a chain of pharmacies, but health insurance company Aetna, and Pharmacy Benefit Manager (PBM), Caremark, among other big businesses. To maximize profits, CVS offers many private label products. To increase those profits further, CVS has begun to sell its own prescription drugs, reports David Wainer for the Wall Street Journal.

    Bottom line, CVS believes that selling its own biosimilars will generate handsome profits. CVS can steer its customers to these generic drugs through its Pharmacy Benefit Manager or PBM, which determines the drugs on many insurance companies’ formularies, including Aetna’s. In the process, CVS can put competitor manufacturers with lower-cost biosimilars out of business.

    The Cordavis unit of CVS Health – lord knows how CVS came up with the name—works with drug manufacturers to create the biosimilars CVS sells. Biosimilars are the generic version of biologicals, prescription drugs made from living cells. The biosimilar market is booming as more blockbuster biologicals, such as Humira, lose their patents.

    Beginning shortly, Humira will no longer be available on CVS formularies. CVS will offer its biosimilar. Similarly, Cigna, which has its own PBM, Express Scripts, will take Humira off its formulary and instead offer its private label biosimilar. For now, the cost will be low for patients, 85 percent lower than Humira’s list price, with no out-of-pocket costs to patients.

    CVS projects that the biosimilar market will grow exponentially in the next five years to $100 million. It was not even $10 million just two years ago. CVS will steer its customers away from brand-name biologicals to its biosimilars and profit big time in the process. Over time, will patients save money and how much? That’s largely up to CVS, an untenable truth.

    The bigger question is how will patients fare as biologicals are replaced by biosimilars? It’s not at all clear; at least for now, it is out of government hands. PBMs, such as CVS Caremark, can and will use their power to determine which drugs people use and at what cost in order to maximize their profits. Before long, some say it’s likely that there will be no prescription drug price competition, only strategies among the PBMs and insurers to maximize profits.

    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.

  • What happens when Medicare Advantage overpayments end?

    What happens when Medicare Advantage overpayments end?

    Tens of billions of dollars a year in Medicare Advantage overpayments are taking a huge toll on the Medicare Trust Fund and driving up Medicare Part B premiums. They also are not deterring Medicare Advantage plans from inappropriately delaying and denying care and coverage. So, what happens when the administration or Congress ends these overpayments?

    Becker’s Payer Issues reports that Aetna Medicare Advantage plans are losing as much as $2 billion in 2024, in part because many fewer of them will receive a four-star rating or better. As it is, the stars are a joke and do not reflect, for example, whether a Medicare Advantage plan engages in widespread inappropriate delays and denials of care. But, a four or five-star rating means real money to the Medicare Advantage plans. Without that money, these Medicare Advantage plans might look for other ways to maximize profits. Will inappropriate delays and denials increase? Will the quality of the provider networks suffer?

    CVS Health owns Aetna. It is losing money because of the reduction in number of its four and five-star Medicare Advantage plans. It is also losing money because of a contract it lost with Centene, a Medicare Advantage plan. CVS Health has been providing pharmacy benefits to Centene Medicare Advantage members.

    Here, you should take note: If you are in a Medicare Advantage plan and get prescription drug coverage, don’t assume you are getting the lowest price. Always check for other ways to get your drugs that could possibly save you more money, such as through Costco mail-order or CostPlus Pharmacy. The full cost of the drug without insurance could be less than your Medicare Part D copay.

    CVS Health continues to invest heavily in getting more Medicare Advantage enrollees. The flawed Medicare payment system pays their Medicare Advantage plans more when their enrollees have more diagnosis codes, even when they do not cost their Medicare Advantage plans more to treat.

    Today, CVS Health has 3.4 million Medicare Advantage members. And, it expects a 12 percent increase next year. UnitedHealth and Humana are the two insurers with the highest Medicare Advantage enrollment.

    CVS Health recently purchased Oak Street Health, a primary care provider group, which will help ensure that they have more control over the diagnosis codes providers give to their patients. CVS Health also says it will enable them to improve their star ratings.

    [This post has been edited to correct a factual error regarding the relationship between Centene and CVS Health.]

    Here’s more from Just Care:

  • Large corporate entities drive major generic drug shortages

    Large corporate entities drive major generic drug shortages

    Yes, we are facing drug shortages in the United States, the wealthiest country in the world. The result is that many Americans with cancer and other deadly diseases are not able to receive treatment, reports Christina Jewett for The New York Times. Three large corporate entities likely are responsible for the drug shortages but are not accountable.

    There are literally hundreds of prescription and over-the-counter drugs that Americans cannot get, including drugs that treat strep throat, lung cancer, breast cancer and ovarian cancer. The drugs are generic, meaning that they generally do not command the prices that pharmaceutical companies charge for brand-name drugs. It seems likely that somehow the goal of maximizing profits is behind the generic drug shortage.

    One possible immediate solution to the generic drug shortage would be for the US to open its borders to the importation of these drugs from verified pharmacies abroad. While today these imports are not legal, no one has ever been prosecuted for purchasing them for personal use. But, that solution does not appear on the table.

    Instead, Congress is considering handing pharmaceutical companies more money through lower taxes as a carrot to manufacture the drugs we need. I would imagine that would only induce them to keep making limited supplies of generics so the tax benefits continue. Congress might be better off having government take control of the prescription drug supply-chain to ensure that supplies are adequate.

    The Food and Drug Administration (FDA) wants the White House to focus on the economic challenges facing generic drug manufacturers. Today, almost all generic drug purchases come from just three entities. Those entities, such as Red Oak Sourcing and Clarus ONE, include big retailers such CVS Health and Walmart. You can bet they are doing what they can to maximize their profits.

    One academic expert, Dr. Kevin Schulman, who teaches at Stanford Medicine, argues that these entities use their leverage to demand super low prices from the generic drug manufacturers. When the manufacturers don’t deliver, it’s not their problem. They are not accountable. Rather, they profit off of the brand-name drugs they sell, and it’s the patients who suffer because their generic drugs are not available.

    One big manufacturer of generics, Akorn, closed down. It had made 100 generic drugs, including albuterol and a drug that treated lead poisoning.
    There is at least one promising domestic solution, Civica Rx, a non-profit that manufactures prescription drugs, which you can read about on Just Care here. Civica was started to ensure a robust supply of critical generic drugs.

    Here’s more from Just Care:

  • New York sues CVS for depriving safety net hospitals of millions of dollars

    New York sues CVS for depriving safety net hospitals of millions of dollars

    If you think that corporate health care, be it administered by UnitedHealth, Amazon or CVS, is better than government health care, consider what’s happening in our health care system today. More and more Wall Street firms are buying up bigger and bigger pieces of the health care industry and, each time they do, it puts health care in the US on less sure footing. New York’s Attorney General is suing CVS to prevent it from depriving safety net hospitals of millions of dollars, undermining their ability to care for their patients and survive, Paige Minemyer reports for FIERCE Healthcare.

    According to Letitia James, NY’s Attorney General, some of New York’s hospitals serving low-income vulnerable populations lost millions of dollars in prescription drug discounts under their 340B programs because of CVS. As CVS has grown, it allegedly exercised its power over these hospitals to make them work with its subsidiary, Wellpartner in order to get 340B drug discounts. In the process, CVS made it harder for these hospitals to get the discounts. As a result, the hospitals had less money to care for their patients.

    According to James, “CVS’s actions are a clear example of a large corporation using its clout and power to take advantage of institutions and vulnerable New Yorkers, but my office will not allow it. We are taking action to stop CVS’s harmful practices and recoup critical funds to improve health care for our communities. When powerful corporations undermine the health and wellbeing of vulnerable communities in New York, they can expect to hear from my office.”

    CVS bought Wellpartner five years ago. It then told hospitals that in order to provide them with prescription drugs, they would have to use Wellpartner to oversee their 340B programs. James alleges that this requirement violates New York State antitrust laws.

    CVS denies the charges. It claims it has saved New York more than $200 million on prescription drugs and made it easier to get prescription drugs through the 340B program. Of course, it does.

    Here’s more from Just Care: