RxAdvocate February, 2025 — Newsletter

February 2 RxAdvocate February, 2025 — Newsletter

Federal Trade Commission Exposes PBM Practices

The Federal Trade Commission (FTC) released its second interim report on the role of pharmacy benefit managers (PBMs) in drug price markups, particularly for specialty generic drugs treating conditions like cancer and HIV. The report highlights that the three largest PBMs—Caremark Rx, Express Scripts, and Optum Rx—marked up these drugs by hundreds or even thousands of percent when dispensed at their affiliated pharmacies, generating over $7.3 billion in revenue between 2017 and 2022.
The FTC also found that PBMs reimbursed their affiliated pharmacies at higher rates than unaffiliated ones and engaged in spread pricing, where they billed plan sponsors more than they paid pharmacies for drugs. These practices contributed to rising costs for employers and patients, with expenditures on specialty generics increasing at annual rates of 21% for commercial plans and 14-15% for Medicare Part D.
While Express Scripts dismissed the report as misleading, the other two PBMs have yet to comment. Experts warn that plan sponsors must scrutinize their agreements with PBMs to ensure compliance with fiduciary responsibilities under ERISA. The FTC has called for further scrutiny of PBM pricing practices, while industry groups have urged Congress to classify PBMs as fiduciaries, though no legislative action has been taken yet.

The pharmacy benefit management (PBM) industry continuously advances. In recent years demand for transparency and the plead for more affordable, effective treatments, and innovative therapies have presented extraordinary challenges and opportunities. Four major trends stand out as pivotal in 2025 and beyond: the movement toward transparent PBM models, the expansion of GLP-1 therapies, the rise of biosimilars, and integration of high-cost gene therapies.
Employers have grown skeptical of traditional PBMs as legal and regulatory scrutiny intensify with many citing misaligned incentives and escalating drug costs. Transparent PBMs offer employers direct access to pricing data, creating a level of accountability and trust that traditional models struggle to match. As the GLP-1 market continues to expand, demand is expected to grow. Sustainable, transparent strategies to manage cost and clinically appropriate access must be prioritized. Innovative programs and flexible benefit designs offer clients solutions for improved member outcomes. Biosimilars continue to disrupt the market with Stelara becoming the next big biosimilar transformer. Biosimilars are clinical and cost-effective alternatives to high-cost specialty biologic medications. As more biosimilar disruptors enter the market, there is a market shift towards these products as providers, members, and plan sponsors gain comfortability. Gene therapies offer a remarkable opportunity for life changing treatment and profound financial challenge for plan sponsors. Coverage decisions become more complex as the market continues to grow requiring PBMs to weight patient eligibility, treatment effectiveness and financial sustainability.

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American Heart Month

American Heart Month is observed in February and aims to bring awareness to heart disease. During the month of February, it is encouraged to participate in making healthier lifestyle choices and utilizing preventive measures to help support overall well-being. The most common type of heart disease, called coronary artery disease (CAD), occurs when plaque buildup in the arteries inhibits blood flow to the heart. The most common contributors to plaque buildup are things such as high blood pressure, smoking, and too much sugar in the blood.
There are numerous ways to improve overall health, many of which focus on implementing or maintaining a balanced diet. To support a healthy functioning heart, it is suggested to cut out processed foods, limit added sugars and limit alcohol consumption. Studies also suggest stress management and an active lifestyle can help lower the risk of developing heart disease.
February is also Congenital Heart Disease (CHD) Awareness Month. CHD is defined as a birth defect that affects the structure and function of the heart, and is the most common type of birth defect, affecting about 1 in 100 babies (40,000 babies in the United States every year).The more severe types of CHD require open-heart surgery immediately after birth, sometimes more than one in the first few years of life. Click the resource below to learn more about CHD and how you can get involved and raise awareness.

Happy Valentine’s Day

Valentine’s Day is a time to appreciate our loved ones, and we can look after our heart health in the process. Below are a few easy swaps that can ensure we are not only taking care of our health, but our loved ones during this special time

1. Opting for a fruit basket instead of chocolate is a great way to cut back on added
   sugars for the day.
2. If chocolates are a must, consider enjoying them over the month by freezing some for later.
3. Preparing a home-cooked meal for date night is one way to be mindful of ingredients and portion size. It’s also an opportunity to learn a new recipe and spend quality time together.
4. We can still stay on track while eating at a restaurant! Some suggest splitting the
   larger portion menu items with your date, or doing research on nutritional information prior to.
5. Lastly, we can take some extra time this Valentine’s Day to move! Whether it’s a walk in the park with a pet or planning some time to go ice skating, we can help ourselves and others engage in heart-healthy activities.

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