Over the past year there鈥檚 been movement to rein in the three big PBMs, which face little regulation though they help set drug prices and drug choices for 80 percent of Americans and their doctors.
The House voted Dec. 11, 320-71, for legislation that would require the PBMs to change some of the ways they do business. The big three 鈥� CVS Health, Express Scripts, and OptumRx 鈥� have all announced their own reform measures in recent months.听
The bill looks unlikely to pass the Senate, though some of its provisions might eventually become law. Meanwhile, some of the most baffling contradictions of PBM drug pricing are coming to a head.听
Take AbbVie鈥檚 Humira, the . Eight biosimilars 鈥� what ordinary people would call generics 鈥� came onto the market this year, raising hopes of big savings for patients and insurers. Some cost as little as $995 a month, compared to Humira鈥檚 wholesale price of $6,992. 聽
The Pharmaceutical Care Management Association, which represents the big PBMs, told 麻豆女优 Health News in a statement that its members are pushing to use more of the biosimilars. Why then, asks Juliana Reed, CEO of the Biosimilars Forum trade group, did Humira account for 98.5 percent of all sales of the drug and its biosimilars as recently as November?
I鈥檝e been told that AbbVie has threatened to withhold rebates it pays PBMs for some of its other medicines unless they give Humira good placement on formularies, the all-important lists of drugs available to their customers. The PBMs say their formularies provide the best deal for employers, but these are 鈥渁ssertions impossible to verify,鈥� says James Gelfand, president and CEO of The ERISA Industry Committee, which represents large employers.
The PBMs鈥� strategy is purposefully obscure. Negotiations with drugmakers constitute their special sauce and they aren鈥檛 sharing the ingredients. But given that it to develop a biosimilar, the Humira battle is key to the future of biosimilars in general, and to more competition to lower expensive drug prices.
鈥淚f you can鈥檛 break into anti-inflammatory drugs it will be hard to break into any model,鈥� Gelfand said. 鈥淚t鈥檚 the weather vane, the shape of things to come.鈥�
There鈥檚 more weird stuff going on with biosimilars. To get Inflectra, its biosimilar to Johnson & Johnson鈥檚 blockbuster Remicade, onto formularies, Pfizer pays large rebates to insurers, I鈥檝e been told.
That鈥檚 driven down average net prices for Inflectra as well as other versions of the drug.听
Good, right? Not according to rheumatologists, the doctors who typically administer these complicated, infused drugs in their offices.
The doctors say they still have to pay much higher prices to obtain Inflectra from distributors. But their reimbursement from Medicare is reduced because of the rebates, they say. Several rheumatologists told me that the way the math works out 鈥� or rather, doesn鈥檛 鈥� they could lose as much as $20,000 a year on each patient.听
The choice is 鈥渓ose money, or divert the patient to a hospital infusion center,鈥� said Chris Phillips, a doctor in Paducah, Ky., who chairs the American College of Rheumatology鈥檚 insurance subcommittee. The latter is 鈥渕ore expensive and usually not as good an experience for the patient.鈥�
Payment imbalances also have developed for Amgen鈥檚 Avsola, another Remicade biosimilar, and for biosimilar forms of Genentech鈥檚 Rituxan, a cancer drug also infused to treat autoimmune conditions, rheumatologists say.
鈥淭he whole point of biosimilars is to make these drugs more accessible, but they鈥檙e becoming unaffordable,鈥� said Madelaine Feldman, immediate past president of the Coalition of State Rheumatology Organizations.听
Spokespeople for Pfizer and for the Pharmaceutical Care Management Association acknowledged the rheumatologists鈥� dilemma. Each said it was up to the other to resolve the problem.
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