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Benefits in the News > By Subject >

Health plan costs - prescription drugs

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Cost Is Top Reason for Not Filling a Medication Prescription
"Although 97% of Americans who received a prescription for medication in the last 90 days filled it, the most-cited reason among respondents who did not fill their prescription was cost (67%) ... 12% of all respondents said that cost drove them to purchase prescription medication outside the United States." (HealthLeaders Media)
[Opinion] Drawing a Line in the Sand: Employers Must Rethink Pharmacy Benefit Strategies (PDF)
"This report offers a call to action on the key issues and important steps public and private employers can take to: [1] Understand how today's pharmacy benefits model, with multiple parties in the middle, contributes to higher costs in the supply chain; [2] Identify ways to work with intermediaries to reduce unnecessary costs and drive efficiency." (Midwest Business Group on Health [MBGH])
The Price Isn't Right: States' Drug Pricing Transparency Laws
"[S]tates such as Ohio and California have put drug pricing transparency initiatives on their ballots to force the issue.... Vermont was the first state to require greater transparency from drug manufacturers regarding price increases, passing legislation in 2016. But other states' attempts to pass transparency initiatives, including ones this summer in Massachusetts and California, have failed in the face of fierce opposition from the pharmaceutical industry." (Bloomberg BNA)
How Price Transparency Can Lower Healthcare Costs
"Drug prices are expected to increase by 9.9 percent this year ... One of the main causes of frustration among consumers is in their inability to see a clear rationale for why prices are rising and what exactly they are paying for.... With the changing climate in healthcare policy, price transparency has come to the forefront as people consider how to manage their medical spending. Price transparency can help drive down healthcare costs in by increasing pressure on providers to control costs and ensure that patients receive the highest quality of care possible for the price they pay." (Jeffrey Sanginiti, for HFMA)
Health Insurers Enter Fray in Drug Price Fight
"Health insurers are pushing back against a recent report that accuses them of denying some patients coverage for medical products and procedures, alleging it is part of a campaign by the pharmaceutical industry to distract the public from rising drug prices.... [One] study does suggest insurers have some blame regarding patients' rising drug prices, [finding] that 34 percent of patients who were denied coverage for a medication or procedure were forced to forgo the recommended treatment because the insurer would not cover the cost." (Morning Consult)
[Opinion] Curbing Prescription Drug Prices Through the PBM Model
"PBMs can play a critical role in keeping costs in check and ensuring affordable access for all beneficiaries.... [W]ithout PBMs, [Medicare] premiums would be 66 percent higher. Because of PBMs, the Part D program will save more than $1,800 per year per beneficiary ... The savings that PBMs generate for Part D are also highly encouraging for the employers, unions, health plans and others in the private sector working to keep prescription drug costs in check for their employees and members." (Meghan Scott, via Morning Consult)
CMS Issues Part D Premiums for 2018
"The average premium for a basic Medicare Part D prescription drug plan in 2018 will be $33.50 per month, which is a decrease from $34.70 in 2017 ... The decline in the average premium comes despite the fact that spending for the Part D program continues to increase faster than spending for other parts of Medicare, largely driven by spending on high-cost specialty drugs." (Wolters Kluwer Law & Business)
Generic Drug Prices Are Falling, But Are Consumers Benefiting?
"Dozens of old generic drugs have risen in price in recent years, for reasons that include supply disruptions and competitors' leaving the market....Despite these cases, the trend toward deflating generic prices appears to have accelerated as companies have more aggressively undercut each other's prices.... [M]ost of those with health insurance pay a fixed co-payment -- $10, for example -- for each generic prescription, and therefore don't pay more or less, regardless of any fluctuation in the actual price. And even those who pay cash for generics may not notice a drop in price because many are already cheap." (The New York Times; subscription may be required)
Take the Generic Drug -- Unless Insurer Says No
"Consumers have grown accustomed to being told by insurers -- and middlemen known as pharmacy benefit managers -- that they must give up their brand-name drugs in favor of cheaper generics. But some are finding the opposite is true, as pharmaceutical companies squeeze the last profits from products that are facing cheaper generic competition. Out of public view, corporations are cutting deals that give consumers little choice but to buy brand-name drugs -- and sometimes pay more at the pharmacy counter than they would for generics." (HealthLeaders Media)
[Official Guidance] Medicare Projects Decrease in Drug Premiums for 2018
"[CMS has] announced that the average basic premium for a Medicare Part D prescription drug plan in 2018 is projected to decline to an estimated $33.50 per month. This represents a decrease of approximately $1.20 below the actual average premium of $34.70 in 2017.... The decline in the average premium comes despite the fact that spending for the Part D program continues to increase faster than spending for other parts of Medicare, largely driven by spending on high-cost specialty drugs." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
PBMs Are Targets in Nevada's Diabetes Drug-Pricing Transparency Bill
"Nevada's Senate Bill 539 places new reporting requirements on pharmaceutical manufacturers and PBMs for drugs that are determined to be essential for treating diabetes. Pharmaceutical sales representatives and some non-profit organizations are also faced with new reporting requirements under the law.... The new law also creates a fiduciary relationship between PBMs and third parties that contract with the PBM for pharmacy benefit management services." (FisherBroyles, via Lexology)
Will Point-of-Sale Rebates Disrupt the PBM Business?
"Since 2011, the difference between pre-rebate costs (known as gross costs) and post-rebate costs (known as net costs) has grown so that the 'gross-to-net bubble' is worth approximately 10% of all Pharmacy spend -- or about $37 billion.... PBM financial improvements are overwhelmingly -- usually 70% or more -- due to higher rebates instead of better discounts or lower fees.... [S]ince rebates are paid to the plan sponsor, members on High Deductible plans still see higher costs ... [S]ome PBMs are offering 'Point of Sale' rebates, where the member on a High Deductible plan sees their cost immediately reduced by the rebate. This approach benefits the member, yet the plan sponsor needs to approve this approach as it affects net plan costs." (Mercer)
[Opinion] Myth vs. Fact: What's Behind Drug Prices
"Drugmakers say they set high prices that reflect the cost of researching and developing medicines. Fact: High prices have little or nothing to do with drugs' innovation or efficacy for patients.... [Further, pricing] is based on what already exists, and competitors use shadow pricing to drive each other's prices higher.... Drug companies argue high prices are needed to fuel innovation. Fact: Instead of promoting true medical advances, a common business strategy in the pharmaceutical sector is to buy the rights to older drugs and then immediately jack up the prices.... [Further, the] numbers keep telling a different story." (America's Health Insurance Plans [AHIP])
Link Between Rising Generic Drug Prices and Market Competition Levels
"Of the 1120 generic drugs included in the study period, there was an average price increase of 30%, while the weighted price (baseline market size was used at continuous variable) decreased by 14.2%. However, drugs in the group categorized as low-competition demonstrated a 63.8% increase in average price; there was a 43.8% increase for those in medium competition, and 9.7% increase among those in high competition." (American Journal of Managed Care)
Ohio Takes Drug Price Measure to Voting Booth
"More than $109 million was spent last year to defeat California's Proposition 61, which would have prohibited the state from purchasing prescription drugs at a higher price than what the Veterans Affairs Department pays. Ohio voters will take up a similar proposal in November amid growing public outcry over the climbing cost of prescription drugs." (Bloomberg BNA)
Getting to the Root of High Prescription Drug Prices: Drivers and Potential Solutions
"This report documents 10 major problems that play a role in high U.S. prescription drug prices.... This report also discusses a broad range of feasible policy actions that have been proposed by various stakeholders, experts, and researchers and could be further developed by policymakers to address high drug prices. Some of the actions identified will have a direct impact on pricing, while others may have an indirect impact but could lead to other favorable outcomes." (The Commonwealth Fund)
[Opinion] Unaccountable Benefit Managers: How PBMs Put Profits Over Over Patients
"PBMs use their outsized power to reap tremendous profits, particularly through a variety of different fees with different names known broadly in the industry as 'Direct and Indirect Remuneration' or 'DIR' fees. DIR fees are charged to pharmacies months after a patient buys a prescription. Ostensibly in place to incentivize pharmacy performance, DIR fees only serve to increase PBM profits. In fact, they have no basis in regulation or law and are just part of an already convoluted system that PBMs have rigged to boost their bottom line at the expense of patients." (Jeff Vacirca in Morning Consult)
[Opinion] NCPA Statement to the Senate HELP Committee on the Cost of Prescription Drugs: How the Delivery System Affects What Patients Pay (PDF)
"Since their inception, PBMs have morphed from claims adjudicators into little known and largely unregulated corporate giants that exploit their strategic position at the 'middle' of nearly all drug transactions in the U.S. to extract profits from the upstream and downstream participants in the drug supply chain while providing questionable value to the ultimate consumer. PBMs are also heavily involved in and reap enormous profits from their involvement in federally supported or subsidized health care programs, like Medicare and Medicaid." (National Community Pharmacists Association [NCPA])
[Opinion] Manhattan Institute Testimony to the Senate HELP Committee on the Cost of Prescription Drugs: How the Delivery System Affects What Patients Pay (PDF)
"Broadly speaking, robust generic competition, along with the advent of large and sophisticated payers, has kept the relative share of health care costs attributable to medicines broadly stable, even as new medicines have become a cornerstone of treatment for acute and chronic illness. However, there are real challenges facing the health care system today, specifically for patients with serious chronic illnesses who are facing high coinsurance or deductibles largely for what are called 'specialty' medicines, and that challenge needs to be addressed." (Manhattan Institute for Policy Research)
Capitol Hill Debate Over Drug Prices Shifts to PBMs
"While lawmakers continue to disagree about the pharmaceutical industry's role in soaring prices for medicines, there are bipartisan calls on Capitol Hill to probe the middlemen in the distribution chain: pharmacy benefit managers. The new focus comes amid an effort by the drug industry to shift the blame from drugmakers, which have faced the brunt of the public backlash for exorbitant pricing, by exposing what it considers opaque business practices by PBMs." (Morning Consult)
Medicaid Prior Authorization and Opioid Medication Abuse and Overdose
"Health insurance payers can implement policies to help curb the opioid epidemic.... Enrollees within plans that subjected opioid medications to [Prior Authorization] policies had lower rates of opioid medication abuse and overdose after initiating opioid medication treatment." (American Journal of Managed Care)
Express Scripts Sues Maker of Overdose Drug, Intensifying PBM Feud
"Drug makers and some members of Congress have accused Express Scripts and other benefit managers of operating in the shadows, pocketing an undisclosed share of the payments they exact from drug makers even as consumers are asked to pay inflated prices for the medicines they need.... The lawsuit ... provides some tantalizing details about the company's dealings." (The New York Times; subscription may be required)
Prescription Drug Price Rebates May Raise Out-of-Pocket and Federal Spending
"Proponents argue that rebates result from vigorous negotiations that help lower overall drug costs. Critics argue that rebates have perversely increased the costs patients pay out of pocket, as well as the costs for Medicare as a whole. This [article] discusses how the availability of rebates for drugs covered by the Medicare Part D program may raise costs for patients and Medicare while increasing the profits of Part D plan sponsors and pharmaceutical manufacturers. Two policy alternatives are herein proposed that would reconfigure cost sharing to lower patient out-of-pocket costs and reduce cost shifting to Medicare." (The JAMA Network)
Insurers Digging Through the Numbers on Oncology Treatments
"Based on a Cigna study, less than 1/2 of the oncology drugs approved from 2009-2014 have a known survival benefit. There are numerous examples. One is a regime of 5-FU + Leucovorin at a cost of $5,000 per treatment with an estimated survival outcome of 12 months versus the drug Xeloda which costs $30,000 and estimates survival at 13.2 months." (Frenkel Benefits)
Best Practices for Managing Costs of Orphan Drugs (PDF)
"The overarching 'best practice' management approach for specialty drugs in the medical benefit is to: [1] pay only reasonable costs for drugs, administration, and related fees; and [2] pay only for drugs that are clinically appropriate for the patient.... [T]hese 'simple' objectives aren't easy to carry out for specialty drugs administered in medical sites of care for two reasons.... First, medical claims may be billed with limited information.... Second, drug pricing in the medical benefit is highly, and inappropriately, variable." (Archimedes, via Chelko Center for Benefits Management)
[Opinion] NCPA Offers House Committee Suggestions to Enhance Medicare, Increase Access to Prescription Drugs
"NCPA recommended the following: [1] Enact H.R. 1038 (the Improving Transparency and Accuracy in Medicare Part D Drug Spending Act). The legislation would ban retroactive direct and indirect remuneration (DIR) fees on community pharmacies. [2] Strengthen and finalize proposed CMS guidance on DIR and pharmacy price concessions. [3] Review and standardize how Part D plans measure pharmacy quality and performance in community pharmacies. [4] Enact H.R. 1316 (the Prescription Drug Price Transparency Act) to increase transparency into how generic drugs are priced by PBMs and paid for in Medicare." (National Community Pharmacists Association [NCPA])
2017 Milliman Medical Index
"In 2017, the cost of healthcare for a typical American family of four covered by an average employer-sponsored preferred provider organization (PPO) plan is $26,944, according to the Milliman Medical Index (MMI).... The MMI's annual rate of increase is 4.3%.... Prescription drug trends are lower, but still high.... Employees pay a bigger piece of the healthcare cost pie." (Milliman)
Prescription Drug Costs Break Through the Partisan Logjam
"Republicans are almost as likely as Democrats, and more likely than independents, to pick lowering the costs of prescription drugs as a priority for President Trump and the Congress. It's the number two priority in health for all Americans, just behind reducing out of pocket costs in general." (Drew Altman of the Kaiser Family Foundation, via Axios)
No Standing for Union Health Plan Claims Against Sanofi for Free Drug Sample Scheme
"A union health plan lacked standing to bring state unfair trade practices claims against a pharmaceutical company it charged caused monetary damage through a free samples scheme involving the osteoarthritis medication Hyalgan, and a diabetes drug switching scheme, because they failed to specifically allege that the plan or any of its beneficiaries paid, let alone overpaid, for the drug in the relevant states during the relevant time period[.]" [Plumbers' Local Union No. 690 Health Plan v. Sanofi, S.A., No. 15-956 (D.N.J. May 4, 2017)] (Wolters Kluwer)
[Opinion] NCPA Urges Senate to Retain Key Prescription Drug Benefit Provisions of ACA
"[P]harmacist-provided prescription drug therapy is 'incredibly cost effective' in helping improve medication adherence by patients, which in turn 'improves health outcomes and reduces much more expensive interventions, such as emergency room treatment.' ... [Up] to $290 billion in annual health care expenses result from the lack of medication adherence ... [A] leading predictor of adherence is a patient's proximity to and relationship with a pharmacist." (National Community Pharmacists Association [NCPA])
Three Approaches to Controlling Rx Costs
"Analyze the data on prescription drug spend in your plan ... Educate employees on what they can do to lower their Rx costs ... [C]onsider working with an expert to conduct a specialty diagnostic of medical and pharmacy plans to assess the current state and identify areas for improved management." (Mercer)
Drug Maker Sanofi Says It Will Tie Price Increases to Health Spending
"The company says it's adopting a three-pronged approach that includes setting launch prices for its new drugs worldwide by measuring 'value' -- meaning, among other things, how well they work for patients. In the United States, Sanofi will also disclose annual increases in its list prices, before and after the discounts given to health insurers." (The Boston Globe)
Did Medicare Part D Reduce Mortality?
"[The authors] investigate the implementation of Medicare Part D and estimate that this prescription drug benefit program reduced elderly mortality by 2.2% annually. This was driven primarily by a reduction in cardiovascular mortality, the leading cause of death for the elderly. There was no effect on deaths due to cancer, a condition whose drug treatments are covered under Medicare Part B.... [T]he value of the mortality reduction is equal to $5 billion per year." (Journal of Health Economics; purchase required)
Frequently Asked Questions About Prescription Drug Pricing and Policy (PDF)
37 pages. "This report will address frequently asked questions about government and private-sector policies that affect drug prices and availability. Among the prescription drug topics covered are federally funded research and development, regulation of direct-to-consumer advertising, legal restrictions on reimportation, and federal price negotiation. The report provides a broad overview of the issues as well as references to more in-depth CRS products. The appendixes provide references to relevant congressional hearings and documents ... and a directory of CRS prescription drug experts[.]" [Report R44832, May 2, 2017] (Congressional Research Service [CRS])
Rising Costs for Patented Drugs Drives Growth of Pharmaceutical Spending in the U.S.
"Analysis of a seven-year trend ... shows that prescription drug spending has increased 10 percent annually for Blue Cross and Blue Shield (BCBS) members since 2010, an overall rise of 73 percent. This upward trend is due to a small fraction of emerging, patented drugs with rapid uptake and large year-over-year price increases that are more than offsetting the continued growth in utilization of lower-cost generic drugs.... [W]hile consumer out-of-pocket costs have risen just three percent annually for prescription drugs in total, they have risen 18 percent annually for patented drugs. Current trends suggest that this rapid rise in drug trend costs is likely to continue in future years." (Blue Cross and Blue Shield Association)
Attention Turns to Specialty Pharmacy (PDF)
"Specialty biotech drugs represent 1 to 2% of prescriptions yet 35% or more of overall pharmacy costs -- and are projected to reach 50% of costs over the next three years. In the United States, the cost of these drugs is multiples more than in other countries, and their use presents global competitiveness and philosophical challenges for plan sponsors. This article examines specialty drug trends, discusses balancing access to them versus their impact and reviews the current state of specialty drug management." (Benefits Quarterly, published by the International Society of Certified Employee Benefit Specialists [ISCEBS])
The PBM Story: What They Say, What They Do, and What Can Be Done About It
"Pharmacy benefit managers (PBMs) say they reduce drug prices and increase patient access, but the facts just don't bear that out.... PBMs got their start as useful claims processors but then morphed into large corporations more interested in extracting profits from the prescription drug supply chain than in ensuring medication affordability and access. And that's the real story: PBMs have done more to enrich themselves over the past 25 years than they have done to bring down drug costs." (National Community Pharmacists Association [NCPA])
Health Insurance Companies Respond to Opioid Epidemic
"According to a September 2016 study ... the total annual cost of the U.S. opioid epidemic is $78.5 billion, most of which is attributed to insurance coverage. The impact of this crisis is having a significant effect on benefit claim costs and more so on overall productivity of the private employer workplace. With this in mind, this document outlines the posture and reformative contractual changes being taken by insurers in the health insurance industry." (EBCG)
Employers Need New Evaluation Process of PBMs to Control Drug Costs
"For the first time this year, large employers noted a surge in spending on pharmaceuticals as a top cost driver of health costs ... Many companies follow a traditional RFP approach when selecting a PBM. Prescription drugs are listed and the costs associated with each drug are tallied in a spreadsheet. Benefit specialists need to try and understand the way a PBM manages prescription drug spending to get a clearer picture of costs for their organization." (Healthcare Trends Institute)
Cigna Touts Progress in Effort to Curb Opioid Use
"Cigna's effort to tackle the opioid epidemic has resulted in a 12% decline in customers' use of prescribed opioids in the last year ... The insurer said its efforts to combat the opioid epidemic have included analyzing claims data to detect patterns that suggest opioid misuse and notifying those individuals' providers.... Starting in July, Cigna will go further by placing quantity limits on most new short-acting opioid prescriptions." (FierceHealthcare)
California Bill Would Require Disclosure of PBM Rebates
"The bill would require [pharmacy benefit managers] to disclose: [1] The percentage of all oral prescriptions and self-administered drugs that were dispensed through pharmacies affiliated with the PBM and the percentage of oral and self-administered medications dispensed through retail pharmacies; [2] The total amount of discounts or price concessions the PBM received that were attributable to California residents whose drug benefits were managed by the PBM; [3] The amount and types of rebates, discounts or price concessions provided to health care plans that could be attributed to patient use under those plans; and [4] The amount of the rebates, discounts or price concessions that are passed through to enrollees and the total number of prescriptions dispensed." (AISHealth)
[Opinion] Proposed Legislation Would Lower U.S. Prescription Prices
"Among other reforms, the [Improving Access to Affordable Prescription Drugs Act] would curb the monopoly abuses of pharmaceutical corporations that keep prices high, penalize companies that engage in price gouging, finally allow Medicare to negotiate fair prices for seniors, cap out-of-pocket medicine costs in health insurance plans and require transparency from the pharmaceutical industry." (Public Citizen)
Pharmacy Benefit Managers: Market Power and Lack of Transparency (PDF)
"While a plan sponsor faces the direct financial costs of the particular prescription plan being offered to its members or employees, only a PBM has a complete understanding of the prices and costs flowing between the various players involved in prescription plans....[which creates] an environment for conflicts that drive PBMs to work for their self-interests, unbeknownst to the sponsor or beneficiary.... [This article] will evaluate the industry structure, conduct and performance, in order to determine whether there is a presence of sustained market power that poses serious anticompetitive risks for consumers and that requires a public policy remedy." (The American Consumer Institute)
Ask Your Doctor If It's Right for You: Prescription Drug Costs -- and TV Ads -- on the Rise
"[Pharmaceutical advertising] exceeded $6 billion last year, with television picking up the lion's share ... [T]he ads inevitably promote high-priced drugs, some of which doctors say have limited practical utility for the average patient-viewer.... Critics say the ads encourage patients to ask their doctors for expensive, often marginal -- and sometimes inappropriate -- drugs that are fueling spiraling health care spending." (Kaiser Health News)
$89,000 Orphan Drug Gets a New Owner -- and Likely a New Price
"Marathon Pharmaceuticals' controversial $89,000-a-year drug ... is getting a new owner.... PTC Therapeutics announced plans ... to buy the Duchenne muscular dystrophy drug Emflaza from Marathon for $140 million in cash and stock. The drug's new price was not announced.... For years, many American patients have imported the generic version at a cost averaging from $1,000 to $1,600 annually. The cost typically was not covered by insurers." (Kaiser Health News)
U.S. Could Drive Down Drug Prices By Exercising Patent Rights
"When the federal government -- through an agency like the National Institutes of Health -- pays for medical research that leads to an invention that can be patented, federal law gives the government a license to use that intellectual property ... as a check, to ensure that the medicines are available to the public on 'reasonable terms.' But ... the government has never used [that] authority." (National Public Radio)
[Opinion] Myths vs. Facts on Pharmacy Benefit Management Arguments Against Bipartisan Legislation to Control Drug Costs
"[On] March 6, 2017, the trade group for PBMs unleashed an array of misleading and false statements to protest H.R. 1316, The Prescription Drug Price Transparency Act introduced by Reps. Doug Collins (R-Ga.) and Dave Loebsack (D-Iowa). Here is an examination and rebuttal to their critique." (National Community Pharmacists Association [NCPA])
To Save on Drug Costs, Insurer Wants to Steer You to 'Preferred' Pharmacies
"Blue Shield of California wants to create 'a tiered pharmacy network' in its 2018 small- and large-group plans ... If the proposal is approved ... it would affect the coverage of more than 1.8 million consumers, based on 2015 numbers from the [California Department of Managed Health Care].... [C]onsumers still would have a broad selection of pharmacies, but they would have to choose a 'preferred' pharmacy to maintain this year's copayment amount. Outside of that network, consumers could pay up to $50 more for the same prescription[.]" (Kaiser Health News)
Beyond the ACA, the Affordability of Insurance Has Been Deteriorating Since 2015
"Since 2015, larger shares of people with health insurance say they have a difficult time affording their health care costs: from 27 percent to 37 percent for premiums, 34 percent to 43 percent for deductibles, and from 24 percent to 31 percent for copays and prescription drugs." (Henry J. Kaiser Family Foundation)
Value-Based Insurance Design Can Help Drive Medication Adherence with High-Deductible Plan
"[W]hen their employers switched to a high-deductible plan, 41% were enrolled in a plan with a [value-based insurance design (VBID)] benefit that provided free preventive chronic disease medication at no out-of-pocket cost to the beneficiary.... [A]dherence among the patients without the VBID benefit dropped from 76.1% to 73.8%, while adherence remained steady among those with the VBID benefit.... However, the VBID intervention did not appear to impact adherence among certain subgroups." (American Journal of Managed Care)
R&D Costs for Pharmaceutical Companies Do Not Explain Elevated U.S. Drug Prices
"[T]he premiums pharmaceutical companies earn from charging substantially higher prices for their medications in the US compared to other Western countries generates substantially more than the companies spend globally on their research and development. This finding counters the claim that the higher prices paid by US patients and taxpayers are necessary to fund research and development. Rather, there are billions of dollars left over even after worldwide research budgets are covered." (Health Affairs)
Where Does Your Health Insurance Premium Dollar Go?
"Your premium, or how much you pay for your health insurance each month, covers the costs of providing your insurance as well as the medical care you might receive -- everything from prescription drugs and doctors' visits to health improvement programs and customer service. Here is a visual breakdown of where your premium dollar really goes." (America's Health Insurance Plans [AHIP])
Facing Pressure, Insurance Plans Loosen Rules For Covering Addiction Treatment
"Aetna will stop requiring doctors seek approval before prescribing particular medications -- such as Suboxone -- that are used to mitigate withdrawal symptoms, and typically given along with steady counseling.... The change comes as addiction to opioids, which include heavy-duty painkillers and heroin, still sweeps the country.... And it puts Aetna in the company of Anthem and Cigna, which both recently dropped the prior authorization requirement for privately insured patients across the country." (Kaiser Health News)
[Opinion] Fighting Pharmacy Inflation
"With aligned incentives, drug formularies, quantity limits, prior authorization and step therapy can all be effective. However, patients and their doctors are very vocal about any restrictions and as a result the pushback to employers is fervent -- and without these requirements the cards are stacked. In order to control costs, the system must be rebuilt to effectively address rising costs." (Frenkel Benefits)
How Insurers Are Working to Combat Rising Prescription Costs
"Higher cost-sharing ... Quantity limits ... Formulary ... Step therapy ... Limited network of specialty pharmacies ... Performance-driven pricing." (Healthcare Trends Institute)
Policy Recommendations to Promote Sustainable, Affordable Pricing for Specialty Pharmaceuticals
31 pages. "[T]his brief explores the dynamics of the specialty pharmacy market -- including the growth in specialty pharmaceutical development; price and price inflation; increases in utilization for an expanding list of conditions; and the impact of vertical consolidation on specialty drug prices.... [It] identifies areas of opportunity for employers to better manage specialty drugs, followed by a look at public policy barriers to better pricing ... [and] concludes with public policy recommendations for more sustainable, affordable pricing." (National Business Group on Health [NBGH])
[Official Guidance] Text of President Trump's Executive Order: 'Minimizing the Economic Burden of the Patient Protection and Affordable Care Act Pending Repeal'
Signed on Jan. 20, 2017. "To the maximum extent permitted by law, the Secretary of Health and Human Services and the heads of all other executive departments and agencies with authorities and responsibilities under the Act shall exercise all authority and discretion available to them to waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the Act that would impose a fiscal burden on any State or a cost, fee, tax, penalty, or regulatory burden on individuals, families, healthcare providers, health insurers, patients, recipients of healthcare services, purchasers of health insurance, or makers of medical devices, products, or medications.... To the maximum extent permitted by law, the head of each department or agency with responsibilities relating to healthcare or health insurance shall encourage the development of a free and open market in interstate commerce for the offering of healthcare services and health insurance, with the goal of achieving and preserving maximum options for patients and consumers." (The White House, via Fox News)
[Opinion] Can President Trump Reduce Drug Prices? Should He?
"When deciding whether and how much to pay for drugs, most industrialized nations rely to a certain extent on cost-effectiveness analysis. And if a drug is not cost-effective, then the health system refuses to pay for it.... A good first step would be to eliminate rules under Medicare Part D that force insurers to cover many drugs, seemingly regardless of the price.... Without profits from the United States, then the pipeline of R&D will begin to dry up." (David Dranove and Craig Garthwaite, at Code Red)
Six-Month Market Exclusivity Extensions to Promote Research Offer Substantial Returns for Many Drug Makers
"[F]or the thirteen FDA-approved drugs that gained supplemental approval for a rare disease indication from 2005 through 2010, the median projected cost of clinical trials leading to approval was $29.8 million. If the exclusivity extension had been in place, the median discounted financial gain to manufacturers would have been $94.6 million.... Extending market exclusivity would provide substantial compensation to many manufacturers, particularly for top-selling products, far in excess of the cost of conducting these trials." (Health Affairs)
OPM Asks FEHBP Carriers to Focus on Rising Prescription Drug Use and Costs
"All insurance carriers participating in the Federal Employees Health Benefits Program [FEHBP] in 2018 should continue their efforts to effectively manage prescription drug use among beneficiaries while trying to rein in escalating costs ... OPM wants carriers to 'reexamine' opportunities to reinforce or add to management techniques that help balance those dual goals, since rising drug prices and more prescription drug use in health care are driving up FEHBP premiums. According the agency, 25.5 percent of the FEHBP health care budget was spent on drugs in 2015." (Government Executive)

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