Just a quiet health policy week. Well actually, depending on your level of wonkiness, it kind of was? But let’s get into what you need to know.
They’re Here! On Thursday, the Centers for Medicare & Medicaid Services released the “negotiated” prices for the initial ten Medicare prescription drug benefit drugs (Part D); these prices are effective January 2026. So no one benefits for a bit on these.
What was interesting about this in the short term? Not much? The discounts listed are off of the list price which no one actually pays and are probably close to what Medicare and commercial plans already negotiate. Maybe a little more aggressive but negotiations are not public so hard to tell. Either way, these seemed to meet the expectations of the analysts that cover this space. The 79% Januvia discount might be steep and Imbruvica was 38% which is high for an oncology drug that doesn’t usually discount/rebate much (although I believe it is priced higher than its competitors that have better data.) Remember that if they weren’t negotiated, these drugs would all face 10 – 20% off because of the Medicare Part D redesign starting in January. They will owe that % for the 2025 year but in 2026, the government pays plans that portion of it.
Sticking It. GoodRx and Boehringer Ingelheim are partnering to offer a Humira biosimilar for $550 for a one-month supply. The biosimilar market for Humira has been slow to take off; it still maintains an 85% market share and 2 of the 3 big pharmacy benefit managers don’t have a biosimilar Humira on formulary. This likely won’t change behavior for patients who are insured and on Humira because their out-of-pocket maybe less than $550 a month but could be a win for those that are under- or un-insured. Pure opinion here but I am wondering if we’re working toward a time when prescription drug coverage is carved out of employer plans and it is self-pay and/or employers pull apart pharmacy and medical coverage.
O-I-G (TOGO) The Office of the Inspector General (OIG) of the Department of Health and Human Services released a report that found that Stelara cost Medicare and patients more when it was covered under Part D rather than Part B (outpatient services, physician administered.) Two easy reasons – 1) we’re stuck in a system that favors high cost/high rebates and Part D has them and Part B (generally) doesn’t and 2) Patients in Medicare Part B have supplemental coverage like Medigap which often covers a big percentage of the cost of the drug.
Lunch viewing. Mark Cuban was on Jon Stewart and talked about healthcare and pharmacy benefit managers. What happens when someone with money and influence tries to solve a problem; you get Cost Plus Drugs. The healthcare stuff starts around 17 minutes in.
It shouldn’t take a Village. The Washington Post covered the healthcare journey of Olympian Adriana Ramsey who stacked up all the healthcare appointments she could while in France because it was free compared to the United States. I am sure that there are probably lots of different ways to look at it but I just found it sad that this is what patients feel like they have to do, much less an Olympic athlete.