"[CMS] proposed two models aiming to implement international reference pricing approaches for drugs under Medicare ... As proposed, both models would be mandatory for any drug manufacturer wishing to participate in Medicare. Both would assess rebates for certain single-source drugs and biological products 'if the prices exceed those paid in economically comparable countries.' The models share a number of conceptual and design features, but operational differences between Part B and Part D do play out in the models' design." MORE >>
"Plan fiduciaries notched another victory in a much-watched, bellwether case alleging breaches of fiduciary duty for failures to manage the drug costs of employer-sponsored health plans." [Lewandowski v. Johnson & Johnson, No. 24-0671 (D.N.J. Nov. 26, 2025)] MORE >>
"The addition of new, effective weight-loss drugs could help hold down spending on the drugs, by increasing the level of competition and putting pressure on the manufacturers and distributors to hold down prices." MORE >>
"The two models -- GLOBE for Medicare Part B and GUARD for Medicare Part D -- will factor in international prices into the inflationary rebates drug manufacturers must pay to the program for certain single-source drugs and sole-source biologics that are separately payable under Medicare Parts B and D, if CMS finalizes the rule." MORE >>
"The plaintiff is challenging the Iowa law requiring that, among other provisions, 'any willing pharmacy' be included in a prescription drug plan's provider network, including self-insured prescription drug plans governed by ERISA. In October, a federal judge blocked enforcement of several portions of the law, citing potential conflict with ERISA. In its brief, ERIC argued that ERISA preempts Iowa's law because that law directly interferes with prescription-drug benefit plan design and administration [.]" [Iowa Assoc. of Bus. and Ind. v. Ommen, No. 25-0211 (S.D. Iowa Jul. 21, 2025; on appeal to 8th Cir. No. 25-2494)] MORE >>
"[T]wo areas [for PBMs to] focus on in the coming months ... [1] Operate with full clarity on money flow and decision-making (i.e., clearly defined administrative fees) while making the whole process accessible and visible to your clients.... [2] [C]harge a clear administrative fee and return every rebate and discount to the client. This can help your PBM regain trust and relieve some of the strain that could lead clients to seek alternate options." MORE >>
"[Under the the PBM Fiduciary Accountability, Integrity, and Reform (FAIR) Act (HR 6837), a] PBM would be considered a fiduciary to a group health plan if it: [1] maintains a 'prescription drug provider network or prescription drug formulary through the purchase of prescription drugs;' [2] negotiates or aggregates 'rebates, fees, discounts or other price concessions for prescription drugs;' or [3] processes the payment of claims for prescription drugs." MORE >>
"Your at-risk population may be larger than you think, which makes weight-management strategies increasingly important.... Self-funded organizations have more strategic flexibility, but financial modeling is essential before making coverage decisions. ... Evaluate coverage decisions through a workforce stability lens, not just a cost lens. " MORE >>
"Several states are exploring ways to manage the cost and access. Some, including Colorado, now require state-regulated health plans to cover GLP-1s for obesity within existing budgets.... Connecticut lawmakers are examining whether the state could petition federal agencies to pave the way for generic versions or pursue multistate bulk purchasing agreements[.]" MORE >>
"ERIC has long advocated that Congress enact strong PBM transparency and accountability reforms to provide relief for employers and workers nationwide. In addition to applying fiduciary standards to PBMs, ERIC has called for PBM reforms to foster greater accountability and affordability by: [1] Providing comprehensive PBM transparency. [2] Banning so-called “spread pricing.” [3] Requiring 100% pass-through of rebates and payments from drug manufacturers." MORE >>
279 pages. "This proposed rule proposes to implement the Global Benchmark for Efficient Drug Pricing Model (GLOBE Model), a new Medicare payment model under section 1115A of the Social Security Act. The GLOBE Model would test whether a payment model that uses an alternative method for calculating Part B inflation rebate amounts for certain separately payable Part B drugs and biologicals products reduces costs for Medicare fee-for- service (FFS) beneficiaries and the Medicare program while preserving quality of care." MORE >>
"This brief provides an overview of the role of PBMs in managing pharmacy benefits, discusses recent federal legislation focusing on several elements of PBM business practices, and explains the potential federal budgetary impact of this legislation, which would have a relatively modest impact on the federal deficit, based on available CBO estimates." MORE >>
"[E]mployers favor utilization tactics over structural PBM reforms despite rising specialty drug spend.... Unsustainable specialty medication costs could erode benefits budgets and employee affordability.... 69% include pharmacy in medical plans; only 16% use pass-through PBMs." MORE >>
"Doctors and groups representing employers said they're increasingly hearing about companies cutting weight loss drugs out of health plans next year as costs mount.... Some [employers] are starting to wonder whether they're paying more for obesity drugs than the cash prices being offered, which range from $200 to $450 a month depending on the dose ... That's leading companies to think it makes more sense for workers to get the drugs on their own[.]" MORE >>
"The move toward DTC access should not be viewed as a short-term marketing trend, but rather a strategic reconfiguration of the pharmaceutical value chain ... DTC models let manufacturers control pricing, data ownership and delivery. This changes the traditional role of [PBMs] as intermediaries. The launch of TrumpRx further underscores growing policy support for bypassing PBMs entirely." MORE >>
"Traditional excessive fee lawsuits remain a major share of ERISA filings, but the contours of those claims are shifting.... One of the most notable developments of 2025 is the surge in lawsuits challenging how employers use 401(k) forfeitures ... To date, more than 80 cases have been filed since the wave began back in 2023, with over 30 cases having been filed just since May of this year.... Recent years have seen new lawsuits challenging what ERISA group health plans pay for prescription drugs. These cases have faced major obstacles[.]" MORE >>
"The Proposed Rule's exclusion of HRAs from Part D notice requirements would ease the administrative burden for employers offering HRAs and TPAs administering HRAs, but would not change the notice requirements for GHPs that directly offer prescription drug benefit coverage." MORE >>
"[T]he court found that the connection between what plan participants were required to pay in contributions and out-of-pocket costs and the fees the plans were required to pay the PBM was too tenuous. The court cited to J&J's discretion in setting participant contribution rates, which it stated can be influenced by multiple factors unrelated to amounts paid in connection with the prescription drug benefits." [Lewandowski v. Johnson & Johnson, No. 24-0671 (D.N.J. Nov. 26, 2025)] MORE >>
"Just a few weeks after CVS Pharmacy Inc. agreed to pay $18.2 million dollars to resolve alleged violations of the federal and California False Claims Acts ... CVS has once again agreed to pay almost $37.76 million dollars to settle another civil fraud case brought against it by the Department of Justice.... In the stipulation and order of settlement and dismissal, CVS admits, acknowledges and accepts responsibility for being overpaid by government healthcare programs, over dispensing and refilling prescriptions too soon." MORE >>
"A federal judge [has] dismissed the primary claims in a lawsuit alleging that Johnson & Johnson had mismanaged prescription drug benefits for employees. Judge Zahid N. Quraishi ... ruled that plaintiffs Ann Lewandowski and Robert Gregory failed to show they had standing to allege that the company had breached its fiduciary duty under [ERISA]." [Lewandowski v. Johnson & Johnson, No. 24-0671 (D.N.J. Nov. 26, 2025)] MORE >>
"Coverage decisions should align with fiduciary obligations to balance cost with access to care. Keep in mind that the questions (and potential options) may change depending on how your plan is funded (fully insured, self-funded, etc.), the goals and objectives of your benefit offerings, and the current/projected utilization of these prescription drugs for your plan. Here are some key questions to ask your plan advisors, insurers, and PBMs (pharmacy benefit managers)." MORE >>
"As shortages resolved, many clinics, compounding pharmacies and online peptide sellers continued practices that had developed during a period of unusual market pressure. State attorneys general have stepped into the gap, using consumer-protection theories to police misrepresentations, dangerous sourcing practices and improper use of research-grade materials. The FDA is now being asked to join that response." MORE >>
"The state of Colorado ... has placed a price limit on the prescription drug Embrel from Immunex Corp. ... The Colorado Consumer Health Initiative estimates that the price cap could save consumers $32 million in drug spending. About 60% of the 2,500 individuals in Colorado who take Enbrel have private insurance. Before the price cap, patients paid about $4,000 of the annual $58,000 cost of the drug. Now, the price of Embrel is capped at about $31,000 per year, and patients have a payment of about $600." MORE >>
"The court determined that ESI's claim that the Act applies only to consumer-oriented acts or practices is a requirement that does not appear in the statute, which was intended to govern the conduct of PBMs, pharmacies, and pharmacists. Additionally, the court found that ESI's interpretation of the statute would render the enforcement mechanism in the Act 'meaningless.' " [Lackie Drug Store, Inc. v. Express Scripts, Inc., No. 23-1669 (E.D. Mo. 2025)] MORE >>
