Pharmacy Market Watch

Get the latest in pharmacy trends and what’s making news in Premera pharmacy.

Notable trends

GLP-1s

For the first time in two years, a drug other than Humira is our current trend driver for per member per month (PMPM) impact. That drug is Mounjaro (GLP-1 for diabetes), even though it’s not a specialty drug.

Though rebates are available, drug spend has primarily risen due to increased use. At the start of 2020, there was a change in standard of care which made drugs like Mounjaro the go-to treatments for patients with type 2 diabetes because there’s strong evidence that they improve health outcomes. The prior standard of care was to try a generic alternative first. We’re now seeing many starting on a brand drug, like Mounjaro, and generics together. The first generic GLP-1 should be available next summer, but we don’t anticipate drug spend to be lower right away because it doesn’t work as well and it’s a daily versus a weekly injection.

We continue to ensure an ongoing utilization management approach, deny off-label usage (for instance, without a diabetes diagnosis), and we’re continuing to build out and review Fraud, Waste, and Abuse processes to ensure drugs are used as medically necessary.

Pharmacy and medical oncology drugs

Cancer drugs continue to be a trend driver due to increased utilization, particularly of specialty brand treatment options. Treatments for colon and breast cancers have been the top drivers in spend. Early identification of these cancers is key to saving lives and reducing total cost of care. Premera is taking strategic steps to mitigate or reduce these costs by:

• Focusing on member screenings at appropriate times; prevention saves members’ time and expense
• Considering where to add site of service requirements for certain drugs as this drives utilization to the most effective sites of care
• Embedding a pharmacist in our care management teams to support complex escalations for members with cancer

Pharmacy newsroom

• Staffing shortages at pharmacies nationwide
  • Higher rates of turnover and slower rate of filling open positions
  • Access challenges for our members which could lead to disruption for pharmacy services, medications, and vaccines
  • Premera continues to monitor the adequacy of our pharmacy network in this rapidly changing environment.
• Artificial Intelligence (AI) in pharmacy
  • Active lawsuits involving AI in prior authorizations and claims processing
  • Premera uses smart logic for approving claims. Potential denials for medication prior authorizations are manually reviewed by pharmacists, as needed.
  • We’re carefully assessing AI options and all implications before using technology, such as scanning chart notes for required information.
• COVID-19 treatment emergency use ends
  • COVID-19 anti-viral treatments are now migrating to the commercial market.
  • Paxlovid is now available commercially and is our preferred product in 2024.
  • Lagrevio is now available commercially and is a non-preferred product in 2024.
  • Utilization management does not change (will remain at 1 course allowed every 90 days).
  • Both medications may have patient foundation assistance in place if affording the actual medication is an issue and a member is eligible.
  • We’re continuing to promote COVID-19 vaccinations to reduce the rates of transmission and achieve better outcomes.