3+ week, 5+ day ago (128+ words) Drugmakers are scrambling to set up direct-to-consumer programs in response to President Donald Trump's executive orders. Should pharmacy benefit managers be worried? Are the programs good for patients? "For us, it's great. It is saying, "Hey, look, that's the pricing. If you're not getting that pricing, let's work together," says Alan Pannier, Pharm.D., MBA, senior vice president of product strategy for SmithRx, a San Francisco-based PBM that, like many smaller PBMs, promotes itself as a transparent alternative to the larger PBMs. "I don't want to create a whole new channel that just avoids all the things that we are doing to drive down cost," he says. Jacob Sands, MD; Uday Dandamudi, MD Jacob Sands, MD; Brian Vicuna, MD...

8+ hour, 28+ min ago (240+ words) Drug and hospital prices are top employer healthcare concerns as costs rise, but some employers are unable to access their data, finds a survey by the National Alliance of Healthcare Purchaser Coalitions. Employer healthcare costs continue to rise, with high-cost claims and high drug and hospital prices being the biggest concerns, according to the most recent Pulse of the Purchaser survey by the National Alliance of Healthcare Purchaser Coalitions, released in September. (See Table Below) The survey of employers and purchasers found that they continue to want transparency from their pharmacy benefit managers (PBMs) and access to data; however, some are struggling to get the information they need. A third of employers said they cannot get complete claims data, and 4 in 10 said their vendors refused to provide access. Anne Chiang, MD, PhD; Baidehi Maiti, MD, PhD, FACP Anne Chiang, MD,…...

1+ week, 6+ day ago (458+ words) Health benefit costs for employees are projected to rise 6.7% in 2026the largest increase in 15 yearsas employers grapple with escalating prescription drug prices, growing GLP-1 coverage and a broader push to offer diverse, cost-saving health plan options amid mounting affordability concerns. The health benefit cost per employee is expected to increase 6.7% in 2026, rising from $17,496 per employee in 2025 to more than $18,500 next year, according to Mercer's 2025 National Survey of Employer Sponsored Health Plans. This is the highest estimated increase in the last 15 years. Healthcare costs in 2025 were already up 6% from the previous year, driving concerns about healthcare affordability, the survey says. More than a quarter (28%) of workers with household incomes at or below the average were not confident they could afford healthcare, another Mercer survey revealed. The increase in cost of prescription drugs is a major contributor to price. In 2025, prescription drug benefit…...

1+ week, 4+ day ago (281+ words) This year marks the fifth consecutive year Independence Blue Shield has received high marks for their Medicare plans. The Centers for Medicare and Medicaid Services have rated Independence Blue Cross's Medicare Advantage plans high Star Ratings for 2026, specifically their Keystone 65 HMO and Personal Choice 65 PPO plans, which received 4 out of 5 stars, according to an Independence Blue Cross news release. This is the fifth consecutive year their Medicare plans have earned high Star Ratings. Part D prescription drug plans are judged on the quality of member experience, customer service, plan improvements, drug safety and pricing. Ratings are updated annually in October. A 5-star rating is the highest level of performance, while 1 star represents the lowest quality. If a plan receives fewer than three stars for three consecutive years, beneficiaries are granted a Special Enrollment Period for Disenrollment, during which they can…...

4+ week, 1+ day ago (310+ words) Transitions of Care (TRC), Medication Reconciliation Post-Discharge (MRP), and Plan All-Cause Readmissions (PCR) are among the measures that have a major effect the Star Rating of health plans. If you're still using claims data to manage care, you're already too late. When critical information about discharges, medication changes, or ED visits arrives weeks after a critical health inflection point, care managers lose the opportunity to act when it matters most. You're managing complications instead of preventing them. Transitions of care are where coordination most frequently breaks down " and where health plans have the greatest opportunity to influence outcomes across multiple quality measures. The challenge is timing. Members are most open to behavior change immediately following a care event. That brief window of impact demands systems that trigger action in real time. Leading plans are shrinking the gap between clinical events…...

3+ week, 3+ day ago (344+ words) Milliman's Jennifer Cruz says plans are losing rebates because of steep price discounts negotiated under the Inflation Reduction Act. but that they need to be sure that renegotiation of rebate guarantees doesn't get too broad. Starting next year, 10 drugs selected by the CMS will be discounted for Medicare by about 38% off their list price because of a price negotiation program put into place by the Inflation Reduction Act (IRA). In 2027, another 15 drugs will be subject to CMS price negotiation under the IRA. Jennifer Cruz says the downward pressure on price is having a ripple effect on the rebates that manufacturers pass on to payers that, in turn, is affecting the rebate promises that they made to health plans. "What's going to happen is the PBMs won't be able to meet their rebate guarantees, so they're renegotiating rebate guarantees," Cruz, a…...

1+ week, 4+ day ago (680+ words) A pilot program limiting the patient co-pay to $50 could burden Part D plans, depending on whether manufacturers discount their prices " and by how much. A new Medicare Part D and Medicaid pilot program, expected to begin in April 2026, would provide coverage for certain obesity drugs at a $50 copay for beneficiaries. However, many questions remain about how the program will operate and its implications for health plans. The details of CMMI's program for the obesity drugs have not yet been filled in. Until they are, Tracy Baroni Allmon, vice president of market access and health policy at Magnolia Market Access, says, "The big question is if patients are paying $50 and manufacturers have agreed to sell directly to cash-paying patients for $249, how much are the plans actually paying?" The $50 copay limit for weight loss drugs for Medicare was mentioned in the Nov....

2+ week, 8+ hour ago (455+ words) The findings in a new study published in Health Affairs suggest that Semglee's interchangeability status may have partially increased adoption by supporting improved formulary coverage. Improved insurance coverage likely drove increased adoption of Semglee (insulin glargine-yfgn) rather than its status as an interchangeable biosimilar of Lantus, according to new research published in the November 2025 issue of Health Affairs. In their review, the researchers examined three potential mechanisms for biosimilar adoption: what they called a "prescribing channel," where the FDA designation signals quality to doctors; a "substitution channel," where pharmacists can swap biosimilars for originator prescriptions; and a "coverage channel," where insurers improved biosimilar placement based on interchangeability. The analysis included 16,331,724 Medicaid claims and 456,170 employer-sponsored insurance claims for Lantus, Basaglar, or Semglee between 2021 and 2022. Researchers found that Semglee market share increased by 3.70 percentage points in Medicaid and 19.25 percentage points in employer-sponsored…...