{"id":299461,"date":"2025-11-18T16:56:11","date_gmt":"2025-11-18T16:56:11","guid":{"rendered":"https:\/\/www.newsbeep.com\/us\/299461\/"},"modified":"2025-11-18T16:56:11","modified_gmt":"2025-11-18T16:56:11","slug":"pbm-revolution-cubans-stelara-challenge-express-scripts-price-games-u-s-drug-spending-reality-and-the-afp-reckoning","status":"publish","type":"post","link":"https:\/\/www.newsbeep.com\/us\/299461\/","title":{"rendered":"PBM Revolution, Cuban\u2019s Stelara Challenge, Express Scripts\u2019 Price Games, U.S. Drug Spending Reality, and the AFP Reckoning"},"content":{"rendered":"

\"\"<\/a>Happy Thanksgiving, everyone! Before you stretch your stomach, stretch your mind with some fresh food for thought from across the drug channel. In this issue:<\/p>\n

Plus: Has the day of reckoning arrived for shady alternative funding vendors?<\/a><\/p>\n

P.S. Join my more than 66,000 LinkedIn followers<\/a> for daily links to neat stuff, along with sharp and thoughtful commentary from the DCI community.<\/p>\n

What else should you expect for 2026? Find out during my upcoming live video webinar, Drug Channels Outlook 2026<\/a>, on December 12, 2025, from 12:00 p.m. to 1:30 p.m. ET. Click here to learn more and sign up.<\/a> As always, we are offering special discounts if you want to bring your whole team. <\/p>\n


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Best Practices in Healthcare Survey Webinar<\/a>, WTW
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Mark Cuban Cost Plus Drug Company Expands Access with Addition of Starjemza\u00ae (ustekinumab-hmny) to Give Patients More Power Over Prescription Costs<\/a>, PR Newswire
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Cuban\u2019s Cost Plus Drug Company has launched Starjemza\u2014a biosimilar of Stelara\u2014with a cash price that\u2019s a whopping 99% below the reference product.<\/p>\n

Cuban once again exposes the economic contradictions of the drug channel. PBM-affiliated private-label biosimilars have strong formulary positions, despite having much higher list prices than competing biosimilars. See The Stelara Biosimilar Price War: How PBM-Affiliated Private Labels Are Reshaping the Market<\/a>.\n<\/p>\n

Of course, PBMs can lower list prices of their affiliate\u2019s private label drugs at any time, but \u00af\\_(\u30c4)_\/\u00af.\n<\/p>\n

This approach also establishes a powerful cash-pay benchmark that could disrupt many benefit designs\u2014if plan sponsors can break their addiction to rebates and fully embrace truly low-cost products. (It also led to this first rate meme.<\/a>) We’ll see if the WTW survey results above are real. <\/p>\n

This drug pricing distortion was supposed to go extinct. It\u2019s never been more alive.<\/a>, 46brooklyn Research
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Kudos to Antonio Ciaccia and the 46brooklyn Research team for another stellar piece of drug channel sleuthing.<\/p>\n

Their latest report exposes questionable generic drug pricing practices within Cigna\/Evernorth\u2019s Quallent Pharmaceuticals business.\n<\/p>\n

As their analysis shows, the Quallent\u2019s average AWP-to-WAC ratio was 1.38x\u2014well above the industry standard of 1.20x. At least one product had a ratio of 2.00x. Plan sponsors using AWP-based reimbursement could be overpaying substantially.\n<\/p>\n

[Click to Enlarge]<\/p>\n

\"\"<\/a>
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If these figures are accurate, it\u2019s yet another reminder: Always check your contract’s math.<\/p>\n

So far, Cigna has offered no rebuttal or explanation, but I\u2019ll share one if it arrives.<\/p>\n

Drug Expenditure Dynamics 2000\u20132022<\/a>, IQVIA
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IQVIA again uses data to provide a counterintuitive reality check on the political rhetoric.<\/p>\n

Across 12 major countries, net drug spending accounts for only 9% to 21% of total healthcare costs.\n<\/p>\n

Despite the political noise, U.S. drug spending is\u2014and has been\u2014squarely in the middle of the global pack. Note that these figures include spending on both retail and non-retail drugs, net of rebates and discounts.\n<\/p>\n

[Click to Enlarge]<\/p>\n

\"\"<\/a>
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Everything in the U.S. healthcare system is more expensive. That’s one of the reasons that benchmarking one small part of the system\u2014the brand-name drug share of the figures above\u2014makes little sense. See my comments from last May.<\/a><\/p>\n

As usual, this report sparked a spirited online debate<\/a>\u2014although some commenters seemed not to have read past the headline and opened the actual report. \ud83d\ude11<\/p>\n

Cheaper medicines, free beach trips: U.S. health plans tap prescriptions that feds say are illegal<\/a>, CNBC
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Has the day of reckoning arrived for such shady alternative funding programs (AFPs) like PriceMD, Rx Valet, SHARx, and others?<\/p>\n

This powerful CNBC expos\u00e9 reveals how shady AFPs skirt FDA regulations and guidance by sourcing specialty drugs from “unverified suppliers” and “potentially illicit” online pharmacies.\n<\/p>\n

Employers keep chasing these schemes, creating delays, denials, confusion, and real risks for their beneficiaries. One quibble: The article omits the plans\u2019 decision to exclude specialty drugs from the formulary, so that a patient technically has “no coverage” (wink, wink) for the drug.\n<\/p>\n

As I have long argued<\/a>, it\u2019s long past time to hold AFPs accountable and stop these dangerous workarounds.\n<\/p>\n

If you have 30 minutes, I highly encourage you to watch the entire video.\n<\/p>\n<\/p>\n

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