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Health plan costs - prescription drugs


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Prescription Drug Coupons: A One-Size-Fits-All Policy Approach Doesn't Fit the Evidence
"Drug manufacturer coupons used by consumers to reduce the size of their prescription copayments are increasingly under fire by federal and state policy makers, as well as by insurers and pharmacy benefit managers (PBMs). Medicare and Medicaid consider them kickbacks and completely ban their use. Massachusetts has considered a similar move, and California recently outlawed coupons for branded drugs where a generic equivalent exists. New Jersey is considering similar legislation to California's." (Health Affairs)
Reforming Biopharmaceutical Pricing at Home and Abroad (PDF)
30 pages. "Federal policies that affect drug pricing should satisfy two goals. First, domestic drug prices paid by Americans should be reduced. Second, the price of better health in the future should also be reduced by spurring medical innovation. This report considers policy options to simultaneously advance these two seemingly conflicting goals." (Council of Economic Advisers, Executive Office of the President)
How Do Prescription Drugs Affect the Use of Other Health Services?
"Medicare Part D, introduced in 2006, has increased spending on prescription drugs for the elderly, but its impact on other health spending is unclear. The analysis addresses this issue by examining the use of other health care before and after Part D was introduced. The results show that the impact of Part D varied by the type of service: It significantly increased spending on office visits, for purposes such as monitoring the effects of the drugs. But it may have decreased spending on hospital visits by reducing the need for more intensive care, such as surgery." (Center for Retirement Research at Boston College)
As States Target High Drug Prices, Pharma Targets State Lawmakers
"With federal officials seemingly unwilling or unable to come up with legislation to control skyrocketing drug prices, that task is increasingly moving to the states. But so is pharma muscle and money opposing the measures ... [The Pharmaceutical Research and Manufacturers of America (PhRMA)] set the stage in 2016 by establishing a group that ultimately spent $110 million to defeat a high-profile California ballot initiative requiring state agencies to pay no more for drugs than does the federal Department of Veterans Affairs. A PhRMA-linked group spent more than $50 million to defeat a similar ballot measure last year in Ohio." (Kaiser Health News)
HHS Nominee Sees PBMs as Tool to Lower Drug Costs
"Alex Azar, President Donald Trump's nominee to be the next secretary of HHS, suggested during his testimony before the Senate Finance Committee that pharmacy benefit managers (PBMs) would be the most effective tool to negotiate for lower drug costs, and said that PBMs should negotiate physician-administered drugs covered under Medicare Part B." (American Journal of Managed Care)
Consumers, Healthcare Organizations Unaligned on Value-Based Drug Pricing
"Most patients (74 percent) are interested in outcomes-based drug pricing, yet the majority of healthcare organizations (59 percent) are not yet working with drug manufacturers to track care outcomes -- and have no plans to do so." (BDO Center for Healthcare Excellence and Innovation)
Drug Companies, Under Attack for High Prices, Have Started Industry War with PBMs
"[A] 'drug price' is not one number. Drugs do carry published list prices, but few pay them. Instead, drug companies and pharmacy benefit managers, working on behalf of different employers and insurers, establish an agreed price through negotiations that are hidden from consumers. How much the patient pays at the pharmacy counter depends on their insurance plan." (The Washington Post; subscription may be required)
[Opinion] A Call to End Drug Rebates
"Drug rebates, which have grown to astronomic levels, are payments made to [PBMs] that encourage dispensing of one brand over another within a diagnostic category. In insured plans these rebates are shared between the PBM and the health plan that covers the patient. In a self-funded arrangement, the employer is also cut into the pricing scheme. So, with all of this side-pocket profit, there is little incentive to shift patients to the lower-cost drug." (Frenkel Benefits - an EPIC Company)
Drugmakers Raise 2018 Prices by More Than Inflation Rate But Stay Within Self-Imposed 10 Percent Limit
"Allergan Inc raised prices on 18 different drugs, including dry eye treatment Restasis and irritable bowel syndrome drug Linzess, by 9.5 percent ... Amgen raised the price on its blockbuster rheumatoid arthritis and psoriasis drug Enbrel by 9.7 percent and Teva increased prices on its ProAir HFA and ProAir RespiClick asthma inhalers by 6 and 3 percent, respectively." (Reuters)
Managing the High and Rising Cost of Prescription Drug Coverage: Prior Authorization Denial Rates for Specialty Drugs Vary Widely Among PBMs (PDF)
11 pages. "The study suggests there are no industry standards for prior authorization denials.... The huge variance in denial rates [Segal] found among PBMs and the potential impact on a plan's cost and participant satisfaction strongly suggests plan sponsors should consider evaluating prior authorization approval or denial rates in their future requests for proposals from PBMs." (Segal Consulting)
FDA Chief Says He's Open to Rethinking Incentives on Orphan Drugs
"The nearly 35-year-old law created incentives for companies to develop 'orphan drugs' considered not financially viable because they treat rare diseases affecting fewer than 200,000 people. Those incentives include a waiver on millions of dollars in fees, seven years of market exclusivity and a tax break for research and development expenses.... Today, orphan drugs often carry six-figure price tags and pharmaceutical companies readily develop them. In 2016, 41 percent of the new drugs approved by the FDA were orphans. And 2017 is on track to be a record year." (Kaiser Health News)
Drug Industry Spent Millions to Squelch Talk About High Drug Prices
"PhRMA spent $7 million last year to prepare its ubiquitous 'Go Boldly' ad campaign and gave millions to politicians who were up for election in both parties in dozens of states. It lavished more than $2 million on scores of groups representing patients with various diseases -- many of them dealing with high drug costs.... The group also aimed dollars at states where policymakers were considering drug-related measures such as price limits or greater price transparency[.]" (Kaiser Health News)
UnitedHealth Beats Would-Be Class Action Over Drug Costs
"UnitedHealthcare Inc., OptumRX Inc., and others defeated a lawsuit accusing the companies of operating a scheme that charged customers hidden, unauthorized, and excessive fees for prescription drugs. A federal judge ... [said] the would-be class of 'thousands, and potentially millions,' of patients failed to show that the defendants violated [ERISA] or federal racketeering law. In particular, there was no indication the defendants were acting as ERISA fiduciaries when they engaged in the challenged conduct, the judge said." [In re UnitedHealth Group PBM Litigation, No. 16-3352 (D. Minn. Dec. 19, 2017)] (Bloomberg BNA)
District Court Dismisses Class Action Challenge to UnitedHealth PBM Payments (PDF)
36 pages. "Plaintiffs allege ... that they were entitled to pay less than they were charged as copayments or coinsurance under the terms of their plans because their plans entitled Plaintiffs to receive the benefit of the discounted rate ... Plaintiffs allege that they purchased certain drugs on numerous occasions and were overcharged due to OptumRx's contribution calculations, resulting in spreads and clawbacks.... [The plans] do not entitle those ERISA Plaintiffs to the discounted rate as a 'lesser of' payment option when filling prescription drugs at retail network pharmacies. Because those ERISA Plaintiffs do not allege that Defendants violated the terms of their Plans other than by not allowing them to pay lesser, discounted rates, such Plaintiffs fail to state claims for benefits under ERISA Section 502(a)(1)(B)." [In re UnitedHealth Group PBM Litigation, No. 16-3352 (D. Minn. Dec. 19, 2017)] (U.S. District Court for the District of Minnesota)
This Old Drug Was Free; Now It's $109,500 a Year
"The drug ... was originally approved in 1958 and used primarily to treat the eye disease glaucoma ... [T]he price has been on a roller coaster in recent years -- zooming from a list price of $50 for a bottle of 100 pills in the early 2000s up to $13,650 in 2015, then plummeting back down to free, before skyrocketing back up to $15,001 after a new company, Strongbridge Biopharma, acquired the drug and relaunched it this spring." (The Washington Post; subscription may be required)
Teva's New Plan Is to Raise Drug Prices, But It Won't Be Easy
"Cost-cuts, including sweeping layoffs, figure prominently in Teva Pharmaceutical Industries Ltd.'s new two-year plan to turn its business around.... [T]he debt-laden company ... hopes to wring more from its generic drugs business by raising prices. There's just one problem: Generic drug prices have been declining all year, posing a crisis for the industry and prompting the very cost-cutting that Teva just announced." (MarketWatch)
Pharmacy Management: Carving In vs. Carving Out -- What's Right for Your Business? (PDF)
"Carving in occurs when a group contracts directly with a health plan provider for medical and pharmacy benefit services.... Carving out occurs when a group contracts directly with a PBM to administer the pharmacy benefit program. The group holds a separate, direct contract with a health plan provider to administer medical coverage.... There are benefits to both." (Lockton)
House Health Subcommittee Hearing Reviews Complex Drug Supply Chain
"Hearing from 10 witnesses, [the Subcommittee on Health] dug into the manufacturing of, wholesale and distribution of, and payment for drugs, and how each of these stages impacts the cost of medications." (Energy and Commerce Committee, U.S. House of Representatives)
Experts Tell Congress How to Cut Drug Prices
"[1] Allow the federal government to negotiate drug prices ... [2] Speed approvals of safe and effective generics and biosimilars ... [3] Transparency ... [4] Discourage the pharmaceuticual industry's direct-to-consumer advertising ... [5] Limit what Medicare enrollees pay for drugs ... [6] Increasing oversight of a very specific federal drug discount program ... [7] Revise the Orphan Drug Act ... [8] Make sure doctors prescribe drugs for the right reasons." (Kaiser Health News)
Are Drugs Cheaper Using Cash?
"Generic drugs reflect 80% of all drugs dispensed but account for less than 30% of an employer's prescription plan costs. The contracts intermediated by employers are largely targeting big-ticket items (brand and specialty drugs) ... even if they will get repeatedly outpriced on the lower-cost drugs as pricing apps, drugstores and generic manufacturers try to gain market share by publicizing cheaper alternatives to the health plan." (Frenkel Benefits)
[Opinion] The Prescription Drug Supply Chain 'Black Box': How It Works and Why You Should Care (PDF)
23 pages. "[This paper outlines] an approach specifically tailored to addressing the challenges inherent in managing the prescription drug supply chain ... [T]his new model disaggregates the traditional 'Pharmacy Benefit Manager' (PBM) supply chain. This allows for better alignment of incentives among the various stakeholders involved in the process." (The Terry Group, for the American Health Policy Institute)
Prescription Drugs May Cost More with Insurance Than Without It
"In an era when drug prices have ignited public outrage and insurers are requiring consumers to shoulder more of the costs, people are shocked to discover they can sometimes get better deals than their own insurers. Behind the seemingly simple act of buying a bottle of pills, a host of players -- drug companies, pharmacies, insurers and pharmacy benefit managers -- are taking a cut of the profits, even as consumers are left to fend for themselves[.]" (The New York Times; subscription may be required)
[Opinion] NCPA Comments to FTC Shine Spotlight on PBMs
"NCPA's ... policy recommendations ... include: [1] Support for the [DOL's] recommendation to require PBMs to disclose all direct and indirect compensation to ERISA plans, to evaluate whether compensation to PBMs, pharmacies (including those owned by PBMs) and subcontractors are 'reasonable.' [2] Collaboration with DOL to create a standardized definition of what constitutes 'brand,' 'generic,' 'specialty,' and 'rebate' for the purposes of eliminating confusion in ERISA drug plan designs. [3] Endorsement of federal and state transparency efforts surrounding PBM 'maximum allowable cost' lists for generic prescription drugs. [4] Increased scrutiny of the conflicts of interest that can be attributed to PBMs operating as both a reimburser and competitor in the pharmacy marketplace." (National Community Pharmacists Association [NCPA])
[Opinion] Will CVS-Aetna Merger Lower Costs?
"The real cost of health care is treating patients with severe diseases and/or multiple comorbidities. These more severely ill people-who make up the lion share of Aetna's costs-need to see specialists, not PCPs.... [T]he thought that there will be significant efficiencies from merging to very different business entities, markets and cultures likely is wishful thinking. The one key area where there could be cost savings is through lower drug prices.... One benefit of the merger is that health plans can internalize cost offsets." (Healthcare Economist)
CVS-Aetna Merger Could Change How Employers Buy Health Benefits
"CVS and Aetna argue that their deal will lower health care costs for employees of their large corporate customers, giving the company greater clout to negotiate down drug prices and better manage the use of those medicines.... [One consultant] expects this will lead large companies to turn to their insurer for pharmacy benefits the same way midsize companies have." (Society for Human Resource Management [SHRM])
CVS-Aetna Deal to Change How Big Employers Buy Health Benefits
"About 63 percent of large corporations use a separate pharmacy benefit company ... In scale, CVS and Aetna offer a much bigger pharmacy benefits manager than UnitedHealth, which expanded its OptumRx business with the $13 billion purchase of Catamaran in 2015." (Reuters)
Follow the Dollar: Understanding How the Pharmaceutical Distribution and Payment System Shapes the Prices of Brand Medicines
"Drug pricing is a complex and often confusing issue, shaped by a pharmaceutical distribution and payment system that involves multiple transactions among numerous stakeholders. A better understanding of the players involved in the pharmaceutical supply chain, and the role each plays in determining what patients ultimately pay for their prescription medicines, can help consumers and policymakers find answers to their questions and concerns about cost and access to medicines." (Pharmaceutical Research and Manufacturers of America [PhRMA])
The Specialty Drug Challenge: An Executive Overview (PDF)
"While there is no silver bullet to manage specialty drug spend, plan sponsors that adopt a multifaceted approach can mitigate the expected cost increases.... [1] Contracts can incorporate favorable terms ... [2] Stringent requirements can be Imposed by formularies ... [3] Care management teams can add value to specialty Rx exclusive networks ... [4] Manufacturer coupons and incentives can reduce costs ... [5] Site-of-care alignment can reduce costs significantly ... [6] 340B strategy can yield shared savings." (Strategic Benefit Advisors)
Drug Pricing Crisis and the Role of the Intermediary: How Did We End Up Here? (PPT)
14 PowerPoint slides. Topics include: [1] Contributing factors; [2] Independent pharmacy marketplace realities; [3] PBM influence in U.S. supply chain; [4] PBMs, plan benefit design and lack of fiduciary responsibility; [5] PBM revenue streams; [6] Maximum Allowable Cost (MAC) pricing: PBM proprietary drug pricing standard. (National Community Pharmacists Association [NCPA])
Employer Premiums Rise Nearly 7% in 2017 as Employees Absorb More of Health Insurance Cost
"Almost three-quarters (72.6%) of prescription drug plans have four or more tiers, while 27.4% have three or fewer tiers. Even more surprising is that the number of six-tier plans has surged, accounting for 32% of all plans, when only 2% of plans were using this design only a year ago." (Wolters Kluwer Law & Business)
[Opinion] How Ethics and Transparency Can Solve the PBM Crisis
"The pharmacist should be at the center of care coordination to ensure that each prescription is the right medication ... Under a pay-for-performance model, the PBM's goals align with those of the plan sponsor.... The PBM should then facilitate any needed changes to the prescription through the prescriber.... Medications selected for the formulary must be the most effective, regardless of cost or rebate.... PBMs must proactively focus on clinical efficiency and accuracy." (Employee Benefit News)
[Opinion] Start with Pharmacy to Reduce Healthcare Costs
"It's not health insurance that's expensive; it's the cost of healthcare. And the more expensive the drugs, the greater the profits throughout the whole supply chain. While innovation should surely be rewarded, perhaps the prices of drugs should be policed like monopolistic public utilities." (Frenkel Benefits)
Anthem's In-House Drug Plan: What Should Employers Expect?
"Anthem's move shows a trend of larger insurers taking the PBM capabilities in house, instead of contracting with PBMs separately, something that can help when it comes to managing costs.... It could make it easier to have specialty care managed under one umbrella.... There's potential for more transparency over pricing[.]" (Bloomberg BNA)
Lower Rx Cost Trend Increases Projected for 2018
"The rising criticism over soaring drug prices may have caught the attention of some drug manufacturers, as the increase in prescription drug benefit cost trends will be lower in 2018 than in 2017 ... Medical plan cost trend increases are projected to be slightly higher than 2017 projections, a change in direction that may concern plan sponsors given that medical coverage represents the lion's share of their health care costs. Price inflation -- not utilization -- is the leading driver of trend. Rx cost-management strategies and improved vendor contracting are plan sponsors' top priorities." (Segal Consulting)
A Path Toward Understanding and Lowering U.S. Prescription Drug Spending
"Prescription drugs accounted for 17 percent of total U.S. health care spending -- or about $457 billion -- in 2015. And that share is expected to rise over the next decade as drug costs outpace those of all other health care services.... For individuals who purchase health insurance, or who have group coverage from their employer, prescription drugs account for the largest share of their total premium expense -- 22.1 percent on average[.]" (The Commonwealth Fund)
Health Insurer Anthem Brings Pharmacy Business In-House, Taps CVS to Help
"Health insurer Anthem Inc will start managing its billions of dollars of patient prescriptions itself in 2020 ... ending a deal with Express Scripts Holding that had deteriorated into lawsuits over terms. Anthem, which sued the pharmacy benefit manager last year over claims of being overcharged by $3 billion annually, said it would use drug retailer CVS Health Corp to handle prescription fulfillment and claims processing for five years for the new company, called IngenioRX." (Reuters)
[Opinion] NCPA Statement for House HELP Committee Hearing on the Cost of Prescription Drugs: How the Drug Delivery System Affects What Patients Pay (PDF)
"PBMs serve as the 'middlemen' in most prescription drug transactions in the United States. First, they leverage the number of beneficiaries in a plan to negotiate lucrative rebates from pharmaceutical manufacturers. Second, they formulate limited pharmacy provider networks that will supply or dispense these drugs to plans' beneficiaries and in turn, charge plan sponsors for these products.... PBMs extract 'spread' profits from both activities. Unless a plan has negotiated a true 'pass through' contract with its PBM -- and typically only the largest and most sophisticated plans are able to do so -- the PBM will keep a significant percentage of the rebate dollars that they have obtained only by virtue of the number of the plans' beneficiaries for themselves." (National Community Pharmacists Association [NCPA])
Combatting the Prescription Drug Abuse Crisis
"Despite the widespread nature of the problem, 'a lot of employers don't have the information they need to address this issue,' says Don Teater, medical advisor to the National Safety Council. For example, 80 percent of 200 Indiana employers surveyed in 2015 said they have been affected by prescription drug abuse in their workplaces, yet only 53 percent said they have a written policy on using these types of medications at work[.]" (Society for Human Resource Management [SHRM])
California Governor Signs Drug Pricing Transparency Law
"The law ... requires drug manufacturers to give a 60-day notice if prices are raised more than 16 percent over a two-year period. The law also requires health plans and insurers to file annual reports outlining how drug costs affect healthcare premiums in California." (Reuters)
[Opinion] Municipality Sues Over Drug Cost Increase: $40 Vial Now Costs $35,000
"The City of Rockford, IL ... [has] sued drug manufacturer Mallinckrodt Pharmaceuticals over the cost of its drug, H.P. Acthar.... The drug is recently reported to cost $35,000 per vial, but cost only $40 in 2001. Rockford, which spent almost $500,000 on the drug in 2015, is alleging that Mallinckrodt, which obtained Acthar through an acquisition, engaged in monopolistic sales practices by purchasing a competing manufacturer and then jacking costs up. And the suit may have some legs since this cost increase is simply unconscionable." (Frenkel Benefits)
Insurers Are Slow to Approve Pricey New Cholesterol Drugs
"During the first year an expensive class of new cholesterol-lowering drugs was on the market, only one in three patients with a prescription actually received the therapy due to lack of insurance approval and high copays ... The drugs, known as PCSK9 inhibitors, ... can cost up to $14,000 per year[.]" (Reuters)
Value-Based Contracting for Drugs and Medical Devices: An Innovative Solution Impaired by Outdated Regs
"Payors, government and industry have all endorsed the concept of applying value-based contracting to prescription drugs and devices. Significant regulatory obstacles, however, stand in the way of fully recognizing the potential for value-based contracting in the prescription drug and device arena. The current federal regulatory scheme for medicines and devices, which was designed around traditional fee-for-services models, is ill-suited to value-based models." (Pepper Hamilton LLP)
Super Spending: U.S. Trends in High-Cost Medication Use
"An estimated 576,000 Americans spent more than the median household income on prescription medications in 2014. This population of patients grew an astounding 63% from 2013. Further, the population of patients with costs of $100,000 or more nearly tripled during the same time period, to nearly 140,000 people. The total cost impact to payers from both patient populations is an unsustainable $52 billion a year." (Express Scripts)
Hospitals, Health Insurers Biggest Sources of Rising Health Costs
"Of the $240 billion increase in private health insurance spending between 2009 and 2015, hospitals accounted for 50 percent and health insurance administration and profit accounted for 12 percent (a 30 percent increase over that period) ... The U.S. is spending as much on insurance administration as on drugs[.]" (Bloomberg BNA)
High Prescription Drug Cost Trends Projected to Be Lower for 2018
"Drug trends for actives and early retirees are expected to remain in the double-digits, continuing to be much higher than medical trend. Price inflation -- not utilization -- is the leading driver of trend... [T]he cost increases of pharmacy benefits now exceed the cost increases of inpatient hospital claim expenses or physician claim expenses ... [O]nce specialty Rx paid through the medical plan is added to Rx paid through PBMs, the cost of Rx is larger than inpatient, outpatient and professional services for some plans." (Segal Consulting)
Pharmacy Benefit Management of Opioid Prescribing: The Role of Employers and Insurers
"[In] a given year, at a company with 100,000 employees, 61 employees would avoid addiction if prescriptions were reduced to align with the doses and duration of use consistent with the CDC Guideline. For employers, this translates into substantial health care cost savings, as a person struggling with addiction would have more than $15,000 in additional health care costs a year as compared to a person who is not dealing with substance abuse." (Health Affairs)
Amazon in Talks with PBMs Over Pharma Supply Chain
"Amazon has been hiring more healthcare leaders and expanding its drug and medical supply distribution in recent months, spurring rumors the online retailer is stepping into the pharmacy business.... [It] could take 18 months to 24 months before Amazon can achieve pharmacy licenses in all 50 states[.]" (Becker's Hospital Review)
Prescription Drug Spending in U.S. Among Highest Worldwide
"Generic drugs make up 84 percent of the total U.S. pharmaceutical market, which is a larger share than in all other countries, excluding the U.K., which is tied with the U.S. with 84 percent. Followed by the U.S. are Germany with 81 percent, Netherlands with 71 percent and Canada with 70 percent of the share of generic prescription drugs. Lower prescription drug prices in the other countries reflect more centralized processes for obtaining pharmaceuticals and setting coverage." (Wolters Kluwer Law & Business)
[Official Guidance] Text of CMS Memo: Creation of the 2018 Benefit Year HHS-Operated Risk Adjustment Adult Models -- Draft Prescription Drug (RXCUIs) to HHS Drug Classes (RXCs) Crosswalk (PDF)
11 pages. "The 2018 benefit year HHS-operated risk adjustment adult models include twelve drug classes, or RXCs, in addition to age-sex, enrollment duration, and diagnostic categories or hierarchical condition categories (HCCs). This memo describes the criteria used to create the RXCs finalized in the 2018 benefit year Payment Notice final rule, including how CMS determined the inclusion criteria for the underlying drugs. This memo accompanies a draft crosswalk for classifying drugs into RXCs for 2018 benefit year risk adjustment for which the underlying drugs will be updated for 2018 benefit year risk adjustment operations based on more current data." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
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)

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