JustCare

Tag: Prescription drugs

  • Are weight-loss drugs cost effective?

    Are weight-loss drugs cost effective?

    Millions of Americans now take weight-loss drugs, some as a treatment for diabetes but, increasingly, simply to lose weight.  A new study funded by the Blue Cross Blue Shield Association suggests that these drugs might not be cost effective, reports Joshua Cohen for Forbes. Nearly six in ten people stop taking them before they lose significant weight.

    People who take weight-loss drugs—GLP1s—can improve their health, particularly if they eat well and exercise. The drugs can help reduce the risk of heart attacks. They can also help people with chronic kidney disease and non-alcoholic fatty liver disease.

    Some believe GLP1s also can benefit people with sleep apnea and people with joint issues. As of now, Medicare only covers these drugs for people with diabetes and a small group of overweight people at risk for serious heart events.

    To be effective, people must continue to take these drugs, if not for the rest of their lives, for a prolonged period. People who go off them before they have shown clinical benefit tend to regain the weight they lost.

    People with diabetes are less likely to stop taking these medicines, Still, 58 percent of people who start taking them stop before they’ve experienced any real benefit. And three in ten people don’t renew their prescriptions after taking them for just one month.

    Only 32 percent of people who start on a weight-loss drug appear to continue taking them after a year. About one in three working people do not have health insurance coverage for these drugs if they don’t have diabetes. These drugs cost so much that businesses who cover them will drive up insurance costs significantly.

    So, insurers don’t cover these drugs because of their cost, which is insanely high. Moreover, most people don’t continue on them long enough to benefit their health. And, their benefits for those who stay on them appear to be marginal.

    Even people who take weight-loss drugs on an ongoing basis appear to lower their risk of heart failure by just 1.5 percent, according to one recent study. Put differently, one in 67 people on these drugs avoid a serious heart event and virtually none avoid death any more so than people who don’t take these drugs.

    Bottom line, it’s still too early to make a compelling case that insurers should cover weight-loss drugs for people who are not diabetics. At least for now, the data suggest that the costs might outweigh the benefits.

    Here’s more from Just Care:

  • How to avoid overpaying for your prescription drugs

    How to avoid overpaying for your prescription drugs

    In a piece for the New York Times, Rebecca Robbins and Reed Abelson advise readers on how to avoid overpaying for prescription drugs. Most importantly, you should not assume that your insurer is saving you money on your drugs. Too often you will pay more for your drugs with insurance than you would if you paid for your drugs in full, without insurance.

    How is it possible you would pay more for your drugs with employer coverage or Medicare Part D coverage than without it? Three words: Pharmacy benefit managers or “PBMs.” These entities—prescription drug middlemen who work for health insurers and are often owned by them—are responsible for negotiating with pharmaceutical companies for lower-priced drugs. But, they can and do pocket a lot of the savings. They then determine which drugs your insurer will cover and your copay for each drug, your “formulary.”

    Three big corporations own the three biggest PBMs. UnitedHealth owns Optum Rx, CVS owns Caremark and Cigna owns ExpressScripts. These insurance corporations put their shareholders’ interests ahead of their customers’. What’s worse is that our government allows them to upcharge their customers.

    Robbins and Abelson suggest that you might want to know which PBM controls your formulary, but I’m not sure why. Caremark, ExpressScripts and Optum control 80 percent of the prescriptions filled in the US. And, there’s no evidence that any of them offer better prescription drug coverage than any other.

    How do PBMs game the system? In addition to being able to pocket and not pass along to you the discounts they secure from drug manufacturers, they can force you to take a brand-name drug when a lower-cost generic is available. They take money from the brand-name manufacturer to steer you to its drug and away from the generic; they might not include the generic on their formulary.

    Sometimes, PBMs include generic drugs on their formularies, but they charge copays for these drugs that are higher than the full cost of the drugs without insurance.

    What can you do? Always check to see whether you can get your prescription drugs at a lower price from Costco or GoodRx or Mark Cuban’s Cost Plus Drugs or from abroad. You often can. A colleague of mine was told the Medicare Part D copay for his drug was over $300.  When he asked the cost with GoodRx, he was told it was $30!

    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:

  • Will the administration step in to curb prices on drugs developed with taxpayer dollars?

    Will the administration step in to curb prices on drugs developed with taxpayer dollars?

    For more than 30 years, the federal government has failed to rely on the Bayh-Dole Act to reduce the cost of prescription drugs developed with taxpayer dollars. US Senator Elizabeth Warren, along with many advocates, is urging the Department of Commerce to finalize a policy that would specify the federal government’s right to seize prescription drug patents funded by the government on drugs with prices deemed to be “too high.” Partrick Wingrove reports for Reuters on where things stand.

    In early December 2023, the Biden administration said it would issue a policy for taking patents from drug manufacturers when their drug prices were excessive. The policy would give the federal government “march-in rights.” Essentially, the government could give other manufacturers the license to manufacture drugs developed with federal dollars, which are priced too high.

    Not surprisingly, the US Chamber of Commerce is trying hard to keep the policy from people implemented. Rather than accepting that the policy would promote innovation and drive competition, it makes the tired argument that the policy will keep pharmaceutical companies from developing new drugs. As a rule, the pharmaceutical companies use their power to make new versions of the same blockbuster drugs rather than to develop new drugs to meet unique and important health care needs. Exceptions are few and far between.

    To determine whether a drug’s price is excessive, the government will look at who can afford it and whether the high price of the drug exploits a health or safety issue.

    Under the new policy, the government would consider a list of factors, including whether only a narrow set of patients can afford the drug, and whether drugmakers are exploiting a health or safety issue by hiking prices.

    Here’s more from Just Care:

  • FTC cleaning up junk patents on 20 brand-name drugs

    FTC cleaning up junk patents on 20 brand-name drugs

    Pharmaceutical companies don’t only get to set their prices on brand-name drugs, they can flood the FDA with patents to keep those brand-name drugs without generic competition for extensive periods of time. Thankfully, the Federal Trade Commission (FTC) is challenging what it is calling “junk” patents on 20 brand-name drugs, Bruce Gil reports for Quartz. The goal is to clean up the mess in the drug patent arena, allow generic drugs to enter the market sooner, and bring down drug prices.

    Ozempic is one of the 20 drugs that the FTC claims has junk patents. If not undone, it will take longer for generic alternatives to compete with it. Novo Nordisk will be able to continue to charge insanely high prices for Ozempic. The FTC is also disputing the patents on Saxenda and Victoza.

    As a rule, a drug patent extends for 20 years beginning when the drug manufacturer files the patent. Once the manufacturer files the patent, it can charge what it pleases for a drug.

    Manufacturers tend to file patents as early as they can, usually even before requisite clinical trials are completed and their drugs are approved. They then file more patents as a way to extend their ability to control the price of their drugs.

    The manufacturers claim they need to recoup their research and development investments. But, substantial evidence suggests that these investments do not justify the prices.

    Junk patents generally support small changes to a drug, such as how they are manufactured or how they are taken, e.g., orally or by injection. With Ozempic, the FTC challenge is to a patent on its “injection device with torsion spring and rotatable display.” By having this device listed in the FDA’s Orange Book, Novo Nordisk gets 30 months of additional exclusivity on its drug.

    But, even if the FTC wins its challenges on these 20 brand-name drugs and they are removed from the FDA’s Orange Book, the manufacturers can sue companies for violating their patents. Through these lawsuits, the pharmaceutical companies can continue to quash competition.

    Some say that the FDA needs more time to review patent applications in order to nip them in the bud and deny them where appropriate. One study finds that if those determining whether patents should be issued were given 50 percent more time, more patents would be denied and Americans would spend about $5 billion less each year for drugs.

    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:

  • Medicare Part D drug coverage stunts are rampant

    Medicare Part D drug coverage stunts are rampant

    When it comes to Medicare Part D prescription drug coverage, one thing’s for sure: Medicare Part D coverage stunts will continue without an overhaul. Insurers have way too much room to drive up drug costs for enrollees in order to profit handsomely. Cheryl Clark reports for MedPage Today that Medicare Payment Advisory Commission (MedPac) Commissioners are surprised by the huge variation in generic drug prices and availability among different Part D drug plans. It’s no surprise, it’s the “free market” run amok.

    Commissioners considered why one generic drug can cost someone with Part D coverage $1.06 at one pharmacy and $102 at a different pharmacy, sometimes even the same pharmacy chain. What goes into generic drug pricing? Lots of unknown factors in addition to the cost of manufacturing and dispensing the drug and the pharmacy’s costs. (But, you can be sure it’s all about insurer profits.)

    About 20 percent of Medicare spending on prescription drugs is for generics, and generics represent about 90 percent of the drugs that Part D plans fill. Generics are costing more and more.

    Some basic generic drugs, including cardiovascular drugs, are just plain “out of stock.” The big PBMs can’t even say when they will have these drugs in stock. Is it a supply chain issue? (Editor’s note: A David Dayen story in TAP reveals that 323 drugs are in short supply, many more than in the past, endangering people’s health and lives.)

    MedPac Commissioners want to know more about Medicare Part D, as if we need to know more to fix a multi-headed drug cost problem. The biggest players have so much power that they can keep drugs off the market if that helps them financially. A while back, I reported on a story about CVS not selling certain generic drugs because they profited more from only making the brand-name alternatives available.

    “Tying arrangements” are another cog in the pharmaceutical supply and price wheel. These agreements allow drug wholesalers and pharmacies to set the amount of a brand-name drug discount to the amount of generic drugs a pharmacy buys and the price it pays. Wholesalers can then charge more for generic drugs and give bigger discounts on brand-name drugs.

    In addition, bigger pharmacy chains can bargain for lower costs than independent pharmacies. They can also pay less for the same drug from wholesalers. The manufacturers might be charging the same price for a drug, but the wholesalers do not.

    And, the Part D the insurers don’t help matters, designing formularies that benefit their bottom lines and often cost their enrollees more. For more on the challenges of getting your drugs covered through Part D, check out this post from last week.

    Bottom line: You cannot assume that you are getting your drugs at the lowest cost through your Part D drug plan. You need to shop around. Too often you can pay a lot less without using your insurance. One MedPac Commissioner explained that with “irrational drug prices … beneficiaries in the know have to strategize multiple means to access their meds. GoodRx over here and a mail order for Mark Cuban over there, a patient assistance program over there, and the many other methods that … bypass the local pharmacist.” Of course, those not in the know, often the most vulnerable, pay more than they should.

    The Commissioner expounds on the problem: “It’s bad enough that the plans can dramatically change what medicines they cover and what costs for each year with different utilization management tools. But then to have multiple sources of the least expensive drug is just too much for older adults and adults with disabilities.” What’s worse, as I understand it, Part D plans can change the medicines they cover and their costs throughout the year.

    Michael Chernew, MedPac Chair, appeared not to be aware of this longstanding issue with Medicare Part D drugs, both generic and brand-name. He suggested that it was challenging to determine a way to fix the problem, even though every other wealthy nation has done so through negotiated drug prices.

    Here’s more from Just Care:

  • Medicare Part D plans can make it hard to get prescription drugs

    Medicare Part D plans can make it hard to get prescription drugs

    As you might already know, Medicare Part D plans can make it hard to get the prescription drugs you need. That’s not to say you shouldn’t have Part D coverage because it could protect you from out-of-control prescription drug bills. But, you still might spend less paying for your drugs out of pocket with a discount coupon from GoodRx or through Costco mail order or from a verified pharmacy abroad.

    First, the good news. Beginning next year, your out-of-pocket costs for drugs that Medicare Part D covers will be capped at $2,000 a year. The Inflation Reduction Act, one of President Biden’s big accomplishments is responsible for that limit as well as negotiated drug prices for some of the highest cost drugs in Medicare.

    But, corporate health insurers offering Part D like to make money, so they are finding ways to shift more costs on to their enrollees.Part D insurers are making it hard for their enrollees to fill certain prescriptions. Either these insurers are not covering certain medicines altogether or they are forcing people to go through multiple hoops before they will pay for certain drugs, according to a recent Health Affairs study.

    For the most part, if a Part D plan does not cover a drug, then that drug is not subject to the $2,000 out-of-pocket cap.

    How do Medicare Part D insurers limit their prescription drug spending and/or boost their revenue?

    1. They don’t include certain drugs on their formulary; they now don’t cover 30 percent of drugs, up from 21 percent 13 years ago. Apparently, they are now not covering come drugs that treat cancers and autoimmune disorders.
    2. They promote brand-name drugs for which they get large rebates from pharmaceutical manufacturers and make copays for generic substitutes more expensive or simply don’t cover generics.
    3. They restrict access to drugs through prior authorization requirements. In 2020, they restricted access to 44 percent of them.
    4. They require the use of generics and won’t cover brand-name alternatives.

    Why does the government permit these restrictions?

    Here’s more from Just Care:

  • Some Democrats oppose Biden’s goal of lowering more Medicare drug prices

    Some Democrats oppose Biden’s goal of lowering more Medicare drug prices

    The Lever reports on a cadre of Democratic Congressmen committed to opposing Biden’s goal of lowering more drug prices for people with Medicare. Not surprisingly, these policymakers happen to be the beneficiaries of lots of pharmaceutical industry money. What’s going on?

    The Inflation Reduction Act includes provisions to allow Medicare to pay negotiated drug prices for ten drugs in 2026. It allows Medicare to negotiate drug prices for an additional 150 drugs through 2034. President Biden wants to expand that number to 500 drugs, which would reduce Medicare spending on high-cost drugs and should also reduce people’s copays for those drugs.

    Former President Trump, if reelected, appears interested in weakening Medicare drug-price negotiation. At one point during his presidency he said he supported drug price negotiation, but he has since backed down from that position.

    Democrats Scott Petters of California, Josh Gottheimer of New Jersey, and Wiley Nickel of North Carolina are prepared to go against their president and fight some Medicare drug price negotiation as well. The pharmaceutical industry and other medical industry groups have contributed $300,000 to them in the last year. Gottheimer is considering a run for governor of New Jersey.

    These Democrats are sponsoring legislation that claims to be defending research on orphan drugs, aping the drug industries’ common refrain that negotiated drug prices will compromise investment in research. It is interesting how negotiated drug prices around the world don’t appear to concern them or the fact that Americans are forced to pay three or four times as much as people in other wealthy countries for the same drugs.

    Experts say that pharmaceutical companies will still rake in big profits on orphan drugs with negotiated prices, just not quite as big as they do now. Moreover, the Inflation Reduction Act exempts “orphan drugs” from Medicare price negotiations if they are treating only one rare disease. If Peters, Gottheimer and Nickel get their way, orphan drugs would be excluded from Medicare price negotiations even if they treat multiple rare conditions.

    Here’s more from Just Care:

  • Billions in Medicare savings from Medicare drug price negotiation by 2031

    Billions in Medicare savings from Medicare drug price negotiation by 2031

    A new report from Nicole Rapfogel at the Center for American Progress (CAP) finds that the Inflation Reduction Act’s provision allowing Medicare to negotiate drug prices for its highest cost drugs will reduce drug spending by tens of thousands of dollars a year for millions of people with Medicare and save Medicare millions of dollars a year.

    On September 1, 2024, the Centers for Medicare and Medicaid Services (CMS), which oversees Medicare, will announce the prices it has negotiated with pharmaceutical corporations on ten drugs that treat, among other things, diabetes, kidney disease, blood clots and heart failure. Beginning in January 2026, the cost of these drugs should drop considerably.

    The ten drugs cost Medicare significantly more than other drugs it covers either because they have very high prices or because they are widely used. A total of nine million people currently use their Part D drug benefit to fill prescriptions for these drugs. These ten drugs represent roughly 20 percent of Medicare’s annual drug spending under Part D.

    CAP projects that the price of one insulin product, NovoLog FlexPen will fall $30 a month and the price of one cancer drug, Imbruvica, will fall $6,548 a month. The price of Eliquis, which 3.5 million people with Medicare take, could drop by $123 a month.

    Currently, Americans pay many times more than people in other wealthy nations for several of these drugs. For example, a dose of Stelara, another drug whose price Medicare is negotiating, which treats people with autoimmune conditions, costs $2,900 in the United Kingdom and $16,600 in the US. Moreover, Americans paid $6.5 billion in taxpayer dollars for the development of Stelara.

    While Medicare is only negotiating the price of 10 drugs this year, by 2030 it will have negotiated the price of 80 drugs. CAP estimates that Medicare will save $25 billion as a result of drug price negotiation in the six years between 2026 and 2031.

    Of course, the pharmaceutical corporations are trying to block these price negotiations in the courts, claiming that the government should not be interfering with the prices private corporations set. What they fail to say is that they developed these drugs with $11.7 billion in taxpayer dollars, The Lever reports. And, the pharmaceutical corporations made $70 billion on these drugs in 2022.

    Here’s more from Just Care: