Q3 2022 Excelsior Newsletter

Excelsior’s Opinion on So-Called “Vision Enhancement Products”

by Robert Kordella, RPh, MBA, Chief Clinical Officer

Three products have come to market recently that are being touted as belonging to a new class of drugs — so called “vision enhancement products.” Let’s take a look at each of them. 

Vuity is a convenience item that temporarily mitigates the need for reading glasses to facilitate close-in vision. Reading glasses, often purchased at Walmart or similar retail outlets at individual expense, also temporarily facilitate close-in vision and can be removed and set aside when the need to read passes. Vuity doesn’t appear to meet the tests for prescription benefit coverage. Our opinion is that reader glasses purchased at Walmart or its competitors, at patient expense, remain a solid alternative to Vuity. Vuity is on our Drug Watch List for these very reasons. 

Upneeq temporarily “treats” droopy eyelids. The standard treatment for droopy eyelids is cosmetic surgery performed by an eyelid specialist. Such surgery was, and remains, a long-term, if not permanent, solution to eyelid droopiness. However, most medical coverage does not cover cosmetic surgery, and most, if not all, medical policies consider the repair of droopy eyelids to be a non-covered cosmetic procedure. If the permanent surgical repair of droopy eyelids is considered cosmetic and isn’t covered under the medical benefit, then why should the temporary pharmaceutical treatment of droopy eyelids be covered under the prescription benefit? Our opinion is that it shouldn’t, especially when you realize that the active ingredient in Upneeq is the same as the active ingredient in Afrin nasal spray, which also isn’t typically covered under the prescription benefit. Upneeq is on our Drug Watch List for these very reasons. 

Acuvue Theravision is a contact lens that contains an ophthalmic antihistamine drug, ketotifen. There are several OTC ophthalmic eye drops already on the market, several of which also contain ketotifen (51 of which at last count), most if not all of which are not covered under most prescription benefit plans. Most prescription benefit plans also do not cover contact lenses. The therapeutic need for an ophthalmic antihistamine can be met more cost-effectively by existing OTC treatments, readily available at patient expense, than by using a high-tech contact lens. 

There is no reason, in our opinion, for any of our clients to ever cover any of these products. At a time when pharmacy benefit budgets are being stressed by seven-figure gene therapies, six-figure biologic anti-inflammatory agents, orphan drugs that impact few patients but carry a hefty price tag when you have an eligible patient on your plan, etc., recommending prescription benefit coverage for dubious convenience items doesn’t appear to be fiscally responsible. Nothing in these recommendations would preclude individual members from purchasing these items at their own expense should they choose to do so, but prescription benefit dollars are too precious to be spent so frivolously with such little lasting impact in light of available alternatives. 

Robert Kordella, RPh, MBA
Chief Clinical Officer

Bob has more than 35 years of diverse experience in the pharmacy industry. Over the course of his career, Bob has led clinical and PBM operations teams in successfully managing more than $4 billion in annual drug spend. This was also while limiting per-member-per-year spending growth to levels that have simultaneously drawn industry acclaim and consistently high levels of member and payer satisfaction.

Semglee vs. Lantus

By Ferrin Williams, PharmD, MBA Vice President and Pharmacy Consultant

The first biosimilar, Semglee, has been on the market for over a year. Are plans paying less? 

Lantus is a long-acting insulin administered once per day. In July 2021 the FDA approved the first interchangeable biosimilar insulin product. Having an interchangeable designation means a pharmacist can substitute at the pharmacy. Mylan makes a branded biosimilar called Semglee. Sanofi, the manufacturer of Lantus, also released an authorized generic called insulin glargine-yfgn. As part of the 2022 formulary changes, two large pharmacy benefit managers (PBMs) put Semglee as the preferred long-acting insulin and removed Lantus. They both issued press releases available via links below.1,2 There has been tremendous press around the cost of insulin in the market recently. 

What is Excelsior’s data showing? Using data from 2021 and 2022 we compared the ingredient cost per day supply for both Lantus and Semglee. The average ingredient cost per day supply decreased by 7%. Average ingredient cost per day supply was $10.83 compared to Lantus/generic insulin cost of $11.60 — a fairly modest decrease. Since both Lantus and Semglee are considered brand medications, they continue to garner rebates from the manufacturers. As a plan sponsor, it’s important to ensure you are getting paid rebates on these products if they are part of the PBM’s formulary. Excelsior Solutions pharmacy consultants request information from the PBMs on whether or not they provide rebates on biosimilars to ensure PBMs are being compared fairly in this area during our request for proposal (RFP) process, and plan sponsors are maximizing their pharmacy benefit. 

Cash price: When you compare this amount to a publicly available price, GoodRx currently shows one carton (five, 3 mL prefilled pens) of Semglee, 100 units/mL for around $400. Compare this to the GoodRx coupon price for insulin glargine-yfgn of the same strength and quantity at $150-$180. This is over $200 in savings for the non-branded biologic for a cash-paying member (not utilizing insurance). 

Conclusion: From a gross cost (plan paid + member paid) the amounts are relatively similar for Lantus and Semglee. If per brand rebates are given for Lantus and not Semglee, preferring Lantus is going to be the lowest cost drug for the plan. Per brand rebates are typically over $200 per claim. While we believe biosimiliars will bring down costs for plans in the long run, the initial experiment with Lantus and Semglee shows relative similar costs. 

1 https://www.evernorth.com/articles/express-scripts-will-prefer-first-interchangeable-insulin-biosimilar#:~:text=BLOOMFIELD%2C%20Conn.%2C%20October%2020,Drug%20Administration%20(FDA)%E2%80%93approved 

2 https://www.primetherapeutics.com/news/prime-therapeutics-backs-first-interchangeable-insulin-biosimilar-semglee/ 

Ferrin Williams, PharmD, MBA 
Vice President and Pharmacy Consultant

Ferrin demonstrates strong business acumen combined with natural talent for leadership, providing a variety of large local and national employer groups with strategic consulting and technical service to effectively lower cost of care while improving employee health outcomes. Ferrin is an executive change agent with an in-depth understanding of healthcare administration products across the PBM business. She is known in the industry as an operations strategist recognized by staff and peers as an inspirational leader dedicated to nurturing rising talent and building diverse, cross-functional teams driven by performance. 

Cost Plus Drug Company Update

by Joe Petersen, MBA Vice President

To provide an update to an evolving topic in our industry, we are revisiting our Q1 2022 newsletter article titled Industry Titans Make a Media Splash with Low-Cost Drug Approaches. The topic of this article was to highlight the newly announced Cost Plus Drug Company (Cost Plus) compared to Amazon Pharmacy and their potential impact on the pharmacy benefit and broader insurance industry. Since that article was published, we’ve seen some updates to Cost Plus’ business model, their access to medications, as well as their partnerships with various pharmacy benefit managers (PBMs) and insurance carriers. 

Previously, Cost Plus was a cash-only benefit with no ties to any health insurance carrier which used a transparent model plus a 15% markup, a $5 shipping fee, and a $3 dispensing fee. Cost Plus’ transparency model has remained, but there have been updates to their position in the industry, including partnerships with Rightway and several Blue Cross Blue Shield (BCBS) plans. While there are network relationships established, each PBM/carrier may approach how they deploy that option differently. 

One thing that differentiates Cost Plus from other big business-backed pharmacy initiatives (Amazon Pharmacy) is that they provide more than a distribution channel. Cost Plus owns their own manufacturing facility that focuses on sterile products with the intent to open facilities focusing on additional products. While current manufacturing is limited, they are planning expansion. Cost Plus is also looking at creating a retail distribution footprint. 

In terms of product offerings, Cost Plus currently offers over 800 generic medications at cost, plus 15%, a $5 shipping fee, and a $3 dispensing fee. Cost Plus has discussed goals of increased generic access, including some brands and biosimilars in their offering. 

Based on preliminary analysis, Cost Plus has not proven to provide significant savings for clients; however, as Cost Plus capabilities and medication access expands, Excelsior Solutions will continue to evaluate the offering to determine if it can provide value for clients. 

Joe Petersen, MBA 
Vice President

Joe has over a decade of experience in prescription drug benefit consulting. He has extensive experience assisting plan sponsors select, manage and audit PBM partners. Joe has overseen vendor selection, pricing evaluation, benefit design, specialty pharmacy strategy and various other client engagements supporting clients across a variety of industries. Joe has a deep understanding of employers of all sizes; health systems; labor and trust clients; and presenting to benefits staff, clinical officers, and operational decision-makers. Joe has the ability to collaborate with executive-level staff and business partners in order to execute pharmacy benefit strategies in coordination with both organizational goals and industry trends. 

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