CVS Health’s new drug coverage program that lets self-funded insurers exclude coverage for drugs with a launch price of $100,000 per quality-adjusted life year has led to a schism of opinions in the industry.
CVS executives Troyen Brennan and Syra Singh recently defended the program in a Health Affairs blog post, saying that manufacturers had the upper hand on pricing.
“Until now, PBMs such as CVS Health have had no ability to impact the initial launch price of a drug, which is set solely by the manufacturer, seemingly without regard to the inherent value of the medication or what the payer or patient can afford,” they wrote.
Brennan and Singh were responding to National Pharmaceutical Council Executive Vice President and CSO Robert DuBois’ concerns about the program.
“The reason why it’s a good debate is because there really isn’t a right answer,” Walid Gellad, who studies prescription drug policy at the University of Pittsburgh, tells Vox.
However, the pharmaceutical industry’s concern about reliance on one metric for coverage decisions could hold some water.
“The idea that we base something solely on a cut point determined by one cost effectiveness analysis from ICER is a big step to take,” Gellad said. “It’s like a giant step forward when you don’t know how to walk yet.”