Over the past year there\u2019s 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.<\/p>\n

The House voted Dec. 11, 320-71<\/strong>, for legislation that would require the PBMs to change some of the ways they do business. The big three \u2014 CVS Health<\/strong>, Express Scripts<\/strong>, and OptumRx<\/strong> \u2014 have all announced their own reform measures in recent months.\u00a0<\/p>\n

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.\u00a0<\/p>\n

Take AbbVie\u2019s Humira, the <\/strong>highest-earning drug ever<\/u><\/strong><\/a>.<\/strong> Eight biosimilars \u2014 what ordinary people would call generics \u2014 came onto the market this year, raising hopes of big savings for patients and insurers. Some cost as little as $995 <\/strong>a month, compared to Humira\u2019s wholesale price of $6,992<\/strong>. \u00a0<\/p>\n

The Pharmaceutical Care Management Association<\/strong>, which represents the big PBMs, told KFF 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?<\/strong><\/p>\n

I\u2019ve 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 \u201cassertions impossible to verify,\u201d says James Gelfand<\/strong>, president and CEO of The ERISA Industry Committee<\/strong>, which represents large employers.<\/p>\n

The PBMs\u2019 strategy is purposefully obscure. <\/strong>Negotiations with drugmakers constitute their special sauce and they aren\u2019t sharing the ingredients. But given that it costs up to <\/u>$300 million<\/u><\/strong><\/a> 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.<\/p>\n

\u201cIf you can\u2019t break into anti-inflammatory drugs it will be hard to break into any model,\u201d Gelfand said. \u201cIt\u2019s the weather vane, the shape of things to come.\u201d<\/p>\n

There\u2019s more weird stuff going on with biosimilars<\/strong>. To get Inflectra, its biosimilar to Johnson & Johnson<\/strong>\u2019s blockbuster Remicade, onto formularies, Pfizer<\/strong> pays large rebates to insurers, I\u2019ve been told.<\/p>\n

That\u2019s driven down average net prices for Inflectra as well as other versions of the drug.\u00a0<\/p>\n

Good, right? Not according to rheumatologists, the doctors who typically administer these complicated, infused drugs in their offices.<\/p>\n

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 \u2014 or rather, doesn\u2019t \u2014 they could lose as much as $20,000 <\/strong>a year on each patient.\u00a0<\/p>\n

The choice is \u201close money, or divert the patient to a hospital infusion center,\u201d said Chris Phillips<\/strong>, a doctor in Paducah, Ky., who chairs the American College of Rheumatology<\/strong>\u2019s insurance subcommittee. The latter is \u201cmore expensive and usually not as good an experience for the patient.\u201d<\/p>\n

Payment imbalances also have developed for Amgen\u2019s Avsola, another Remicade biosimilar, and for biosimilar forms of Genentech\u2019s Rituxan, a cancer drug also infused to treat autoimmune conditions, rheumatologists say.<\/p>\n

\u201cThe whole point of biosimilars is to make these drugs more accessible, but they\u2019re becoming unaffordable,\u201d said Madelaine Feldman<\/strong>, immediate past president of the Coalition of State Rheumatology Organizations<\/strong>.\u00a0<\/p>\n

Spokespeople for Pfizer<\/strong> and for the Pharmaceutical Care Management Association<\/strong> acknowledged the rheumatologists\u2019 dilemma. Each said it was up to the other to resolve the problem.<\/p>\n

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This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org<\/a>.<\/em><\/p>\n
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