by Leslie Small
Express Scripts Holding Co. and CVS Health Corp. have in recent
months unveiled new programs that appear designed to transition away from the
PBM status quo.
One factor driving both new programs could be a proposed rule
that's still under review by the Office of Management and Budget, which might
remove prescription drug rebates' safe-harbor protections from the federal
antikickback statute. But one industry expert says it looks less likely that
may actually transpire.
"I think it has more to do with the fact, almost regardless
of that [potential rule], that rebates going forward potentially are going to
be so variable," says David Dross, the leader of Mercer's managed pharmacy
practice. He says the PBMs' moves are a response to "marketplace
demand" for a different type of pharmacy benefits model.
Express Scripts' new National Preferred Flex Formulary allows it
to add to its formulary a newly launched lower-cost alternative to a brand
medication — giving members immediate access to that drug — and lets the PBM
exclude the innovator brand product from coverage.
The first drugs managed through the National Preferred Flex
Formulary will be Asegua Therapeutics' authorized alternatives for the
hepatitis C treatments Epclusa (sofosbuvir/velpatasvir) and Harvoni
(ledipasvir/sofosbuvir).
Under CVS's new Guaranteed Net Cost model, the company will pass
100% of rebates to plan sponsors and "take accountability for the impact
of drug price inflation and shifts in drug mix," the company said in a
press release.
Though the models differ in design and scope, Dross says similar
forces are driving them. "I think there's so much buzz in the marketplace
around rebates, and what they are or aren't," he says. "People are
becoming more conversant about it, so what that does is it sort of shines a
light on all of the various entities in the supply chain, including pharma
manufacturers."
In response to that, manufacturers are experimenting with
different approaches to pricing, which move away from the high-list-price,
high-rebate paradigm, he explains. "And it kind of puts the pressure on
the PBMs to say, 'gee, well, how do we deal with that or address that?'"
Dross adds.
Express Scripts' new formulary is "directly dealing with
that particular dynamic," he says, while CVS's model is more of a
broad-based approach that signals to the market it's open to trying something
new and taking on risk.
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