Managed Care Pharmacy Practice Insights - Fall 2024

Happy fall, ya’ll! So much has happened since we published our first Managed Care Pharmacy Practice blog. There’s no way to summarize it all, but that won’t stop me from trying!

September was an exciting month of headlines:

• First round of Maximum Fair Prices (MFPs) released. CMS released the MFPs for the first ten drugs in the Medicare Drug Price Negotiation Program. For a deeper dive into the numbers, check out this article from JMCP from June.
• The government continues to focus on PBMs. A House Judiciary Subcommittee held a hearing on “The Role of Pharmacy Benefit Managers” (look closely, and you’ll see several of our AMCP staff in the audience!). Subsequently, the Federal Trade Commission (FTC) filed a lawsuit against PBMs, alleging that anticompetitive practices have increased prices. Express Scripts sued the FTC earlier that same week regarding “unsubstantiated, false, and biased claims” in the agency’s July interim report. AMCP CEO Susan Cantrell’s recent JMCP article dives deeper.

In October, more than 2,700 AMCP members came together in Las Vegas for the Nexus meeting, which was an excellent opportunity for networking, education, and so much more. It was fantastic seeing old friends, making new connections, and hearing so many stories about how much everyone won (or lost) at the casinos. Attending for the first time as a staff member, it was incredible to see the behind-the-scenes planning and execution of such a large-scale event and how seamlessly the AMCP team pulls everything together!

In addition, AMCP's annual Access, Affordability, and Outcomes report has been released. In it's second addition, the report looks at the fundamental concepts of managed care pharmacy and provides insight and clarity into how today's changing health care climate can be navigated to improve patient care and outcomes.

Switching gears, as you may have heard, the election is over, and with it also comes the end (for now) of the seemingly endless text messages, mail, dinnertime phone calls, and TV and social media ads. But there are many questions as to what comes next and not a lot of answers just yet. Check out this forecast of the incoming administration and Congress's health policy agenda from AMCP.

A few other notable government-related headlines from the past few months that caught my attention:

• The Congressional Budget Office found that covering anti-obesity medications for Medicare enrollees would add about $35 billion to the federal budget between 2026 and 2034, between $4,300 and $5,600 per user.
• The proposed Medicare $2 Drug List Model (M2DL) could begin as early as 2027, but for now, CMS is seeking input (until Dec. 9, 2024). This voluntary program for sponsors would offer Part D members access to a list of medications for, you guessed it, $2.
• The Advisory Committee on Immunization Practices (ACIP) updated their recommendations on several vaccines. Notably:
  • Pneumococcal conjugate vaccine (PCV) is now recommended for all PCV-naïve adults aged ≥50 years (reduced from ≥65 years).
  • An additional dose of the 2024-25 COVID-19 vaccine is now recommended for patients 65 years and older and those 6 months to 64 years of age who are moderately or severely immunocompromised.

There have also been a number of meaningful drug approvals over the past few months. Selecting just a few to highlight:

• Obecabtagene autoleucel (Aucatzyl), a CAR T-cell therapy referred to as obe-cel, was approved for relapsed/refractory B-cell acute lymphoblastic leukemia.
• Zolbetuximab-clzb (Vyloy) was approved for CLDN18.2-positive gastric or gastroesophageal junction cancer.
• Marstacimab-hncq (Hympavzi), a non-factor product, was approved for hemophilia A and B.
• Dupilumab (Dupixent), already approved for several other conditions, received approval as add-on therapy for chronic obstructive pulmonary disease (COPD). 
• Xanomeline and trospium chloride (Cobenfy) was approved and is the first schizophrenia medication with a novel mechanism of action (targeting cholinergic receptors instead of dopamine receptors) since clozapine was approved in 1989 as the first atypical antipsychotic. 
• FluMist was approved as the first self- or caregiver-administered influenza vaccine for at-home use. 
• Atezolizumab and hyaluronidase-tqjs (Tecentriq Hybreza) was approved as the first subcutaneous anti-PD-(L)1 cancer immunotherapy.

When you hear from me next, it’ll be 2025, meaning a few key Inflation Reduction Act initiatives will have kicked in, including a completely restructured Part D benefit with a $2,000 out-of-pocket limit for prescriptions. The downside? Pharmacy students these days are going to miss out on the joy of explaining the donut hole to unpleasantly surprised patients. 

I wish everyone a fantastic holiday season. See you in 2025! 

Steve 

P.S. We want to hear from you! Email us your thoughts, comments, questions, things you’re seeing in practice, or even just a friendly “Hello!”

Steve Kheloussi, PharmD, MBA, FAMCP
Director, Professional Affairs
Published on November 14, 2024