A Real Rival to the Big 3 PBMs?
Real Endpoints
Real Endpoints, a health-care advisory/analytics firm delivering solutions that enhance appropriate access to innovation
There could be money in transparency.
Blue Shield of California, which last year fired CVS as its PBM (but kept CVS Specialty Pharmacy) in favor of a more transparent way to buy drugs, has now negotiated a $525/month price for a Fresenius-manufactured Humira biosimilar. That’s roughly half what Humira biosims are costing employers and plans (before any rebates) through CVS’s Cordavis, Cigna’s Quallent and United’s Nuvailant.
Blue Shield of California is using Evio Pharmacy Solutions (which it owns along with four other Blues) to manage the program, which will presumably be available for other Blues plans should they, like California Blue Shield, decide to ditch their current PBM contracts.
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Essentially that could create a fourth “private label partner” -- at least on the specialty side. This new partner will likely invite manufacturers of branded drugs, not just biosimilars, to its contracting table. If that fourth player doesn’t now have the number of covered lives the Big 3 PBMs represent, the total will still be substantial. And Blues plans are notably powerful in their home markets. They’ll also have at least one inherent cost advantage over the other PBMs: Evio’s owners are not-for-profits so it may not have the tax burden the Big 3 do.
For biosim manufacturers, however, the picture is increasingly dark. Prices have nowhere to go but down. At some point, absent some miraculous pricing discipline, they’ll drive each other into unsustainable low-net-cost territory. Indeed, one question will be whether, given the fragmentation of the customer base (different PBMs buying different versions), the biosim manufacturers will be able meet the production requirements of major buyers – one of the key criteria for winner-take-all contracting with PBMs. If they can’t guarantee supply, and margins to support it, we’ll likely see the more vulnerable manufacturers pulling out of a business that once looked, and indeed turned out to be, too good to be true.
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5 个月Blues have not been notoriously cooperative with each other in the past but granted they can pull this Evio/Synergie Medication program together, they'll start with the kind of membership -- and therefore pricing leverage for drug contracting -- that will be challenging both for the Big 3 PBMs and the still-membership-challenged PBM start-ups trying to provide friendlier, less opaque alternatives.