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GIC hears PBM briefing on drug-cost trends; commissioners raise concerns about GLP-1 denials and member disruption
Summary
GIC pharmacy consultant Devin Shaw outlined PBM functions and rising cost drivers — notably GLP-1 weight-loss and diabetes drugs — and reported increased prior-authorizations and lower approval rates for those drugs; commissioners described frequent member denials and customer-service problems and asked staff for comparative pricing and appeals data.
Devin Shaw, GIC—s lead pharmacy consultant, briefed commissioners on pharmacy benefit manager (PBM) operations, the role PBMs play in claims processing and rebates, and current drug-cost trends the commission should watch.
Shaw outlined three near-term trends of special interest to GIC: the rapid uptake and high list prices of GLP-1 weight-loss/diabetes drugs (retail list prices cited around $15,000 per year, with uncertain net pricing after rebates), the growing pipeline of biosimilars (which can reduce specialty-class spending), and the potential of pharmacogenomics to tailor treatment. He said GIC is auditing pricing and rebate transparency and has a data request out to PBMs to benchmark acquisition costs against NAADAC/retail comparators.
On utilization management, Shaw said prior authorization affects roughly 2% of total claims but that approval rates for non-specialty prior auths have fallen in some categories (approval rates in those categories were reported in the 63% range, driven largely by GLP-1 criteria). He also told commissioners the PBM data show many appeals and that a substantial share of approvals are overturned on appeal; turnaround-time challenges for external appeals were flagged.
Several commissioners described individual member experiences. Commissioner Bobby Kaplan said he has received frequent member complaints of denied long-standing prescriptions, difficult appeals processes and poor customer service from the PBM vendor (Caremark/CVS). Commissioner Kaplan and others reported members who acquired drugs outside GIC (GoodRx, Costco) or directly from manufacturers after denials. GIC staff said they will analyze PBM pricing and appeals data, benchmark selected drugs against NAADAC and other public pricing sources, and return with follow-up reporting.
The briefing also covered broader affordability controls the GIC uses (procurements, performance guarantees, audits and stewardship meetings) and noted the commission—s contract language seeks to ensure rebates and discounts accrue to GIC. Commissioners asked staff to return with national comparisons and more granular member-experience metrics.
GIC staff did not propose immediate changes at this meeting but committed to follow-up data work, including a comparative pricing analysis and further review of prior-authorization and appeals outcomes.
