Insurers game Part D, pharmacists pay

Let’s start with a story designed to get your blood pressure up. Private insurers, it seems, have found a sneaky way to get themselves some extra money out of taxpayers by gaming the Medicare Part D system, according to CMS data crunched by UC San Diego researchers.

It works like this:

An insurer pays a pharmacy more than normal for a generic med — “much higher rates than what pharmacies spent to acquire the drugs.” It then gets reimbursed from Uncle Sam based on that higher price.

Great — more money for pharmacies! Except for those good ol’ clawbacks. After taxpayers have paid the insurer, it then turns around and hits the pharmacy with a DIR bill. “Double-dipping” is a polite way of putting it.

It’s not chump change: “The results are alarming. We are talking about markups of 6000% or 7000% in some cases,” said one of the authors.

And then there’s the copay, which is often tied to the price of the drug. That puts seniors on the hook, too.

As another author put it, “It doesn’t make sense that insurers would overpay for drugs, then use clawbacks to retroactively adjust payments after the patient has paid their co-payment.”

Oh, it makes perfect sense to us … if you’re an insurance company.

Covid and the next generation

If a baby seems to be developmentally delayed during its first year, it could be because mom had Covid-19 while pregnant. A new study out of Brazil compared infants who had been exposed to SARS-CoV-2 in utero to those who hadn’t.

“Over 50% of the SARS-CoV-2 exposed infants presented ASQ-3 [Ages & Stages Questionnaire] scores below the expected cutoff, with about half classified with neurodevelopmental delay, mainly at 4 and 12 months.”

This is in line with previous studies, and it found that 10% of the exposed infants showed signs of a particular type of brain swelling. Yikes.

DEA threatens Georgia pharmacies

More than half of states (and DC) permit marijuana for recreational or medicinal use, but you know the story: It’s still illegal on the federal level. The feds — through the Obama, Trump, and Biden administrations — have mostly kept their hands off.

But then comes Georgia. Unlike other states, Georgia has specially licensed independent pharmacies dispensing low-THC oil to registered patients, rather than relying on Cheech and Ted’s Feel Good Emporium™.

And thus the DEA, like Smaug the dragon, has opened its eye and taken notice. The agency has been notifying those pharmacies that they risk their licenses.

Even low-THC oil is, according to the DEA, as dangerous as heroin or LSD and has no medical benefit.

If you were expecting advice on how to deal with these letters, sorry to disappoint. We’re not lawyers, and that’s who you should be talking with if you’re one of those pharmacies. (You can also reach out to your AIP member service rep for guidance. Not an AIP member? Maybe now’s the time, huh?)

AIP welcomes friends

We love hosting friends from New York and showing them a bit of Georgia hospitality. In this case it was McKesson’s area vice president Roopa Sangani and Pharmacy Sales Consultant James Campbell who visited AIP VP Jonathan Marquess at the GPhA offices.

“We appreciate Roopa visiting Georgia from New York,” Marquess said. “I really enjoyed our dialogue and discussion on ways we can work together more in 2024. Thank you so much for your support of AIP and GPhA!”

When the feds come marchin’ in

The White House has determined that yes, when it comes to high-priced meds developed with taxpayer funds, the federal government does have march-in rights — the authority to seize the patents to make the drugs more available.

That doesn’t mean it’s actually going to do that. This was more of a legal finding — think of it as a friendly shot across the bow to drug companies.

[The new rules] would allow the government to grant additional licenses to third parties for products developed using federal funds if the original patent holder does not make them available to the public on reasonable terms.

Pharma companies have rolled out their usual arguments: It’ll stifle drug development, hurt patients, open rifts to the Dark Dimension, etc. To be fair, that makes sense here — if you might lose a patent, why bother making the drug?

Because it wouldn’t just be willy-nilly. “The price and availability of that product to the public are among the factors the department will recommend that agencies consider.” I.e., keep the pricing reasonable so people can actually afford the drug and everything will be fine.

Surprising tumor fighter

If you add an interleukin-4 drug like dupilumab to chemo^*, it seems to boost patients’ immune systems and help it fight tumors.

Mount Sinai researchers found that when immune cells entered lung tumors, they acted similarly to how they would during an allergy or asthma attack. So they figured they’d see how an allergy med might affect that. It turned out to make the tumor more responsive to the chemo.

“In fact, one patient whose lung cancer was growing despite checkpoint blockade had nearly all their cancer disappear after receiving just three doses of the allergy medication, and his cancer remains controlled today, over 17 months later.”

^* Specifically PD1 inhibitors

People stick with Wegovy

One of the issues with GLP-1 drugs is that people stop taking them after a year or so, probably because of price or side effects. But here’s an interesting bit of data out of the Cleveland Clinic: It turns out that people are more likely to stay on Wegovy than they are on older weight-loss meds.

Only 13% of patients who started taking Contrave from Orexigen Therapeutics and 10% of those who started on Qsymia from Vivus between 2015 and 2022 were still filling their prescriptions a year later.

Don’t miss the other important point there: It was comparing Wegovy to non-GLP-1 meds. So it might well apply to Mounjaro, Ozempic, Zepbound, and others.

A couple of caveats to note: First, GLP-1s are much more effective for weight loss, so that might explain the higher adherence, but the Cleveland folks didn’t look into that. Also, all the study participants had private insurance, so it’s not clear what their out-of-pocket costs are.