Health Plan Weekly

When CMS on Aug. 15 revealed the prices of the 10 drugs subject to Medicare price negotiation, its much-anticipated disclosure still left many questions unanswered. In the managed care world, the biggest question mark remains how Medicare Part D plans will adjust their formularies in reaction to the new government-set prices — but one industry expert says it will be a while before more clarity emerges. 

“These prices are effective Jan. 1, 2026, so they should not, in theory, impact the 2025 formularies,” which have been largely decided since April, says Jennifer Snow, founder of the health policy and reimbursement consulting firm Apteka LLC.  

More than 30 states last year considered or introduced legislation to reform prior authorization, due in large part to lobbying from physician groups that indicate they are being subject to more PA requirements from insurers, according to a recent analysis from the Georgetown University Center on Health Insurance Reforms (CHIR). While health plans in recent months have touted their reduction in PA mandates, Sabrina Corlette, one of the report’s authors and CHIR’s co-founder, says providers and their staff still are spending numerous hours each week on PA and identify it as a major burden. 

Corlette and her colleagues primarily focused on four states — Arkansas, Illinois, Texas and Washington — that have enacted comprehensive PA reform in the commercial insurance market.  

So far, 2024 has proven to be an eventful year for publicly traded health insurers — and not always in a good way.  

Indeed, during the most recent quarter CVS Health Corp. made waves by adjusting its earnings outlook downward for the third time this year and dismissing the short-tenured president of its Aetna health benefits division due to ongoing Medicare cost pressures.  

Other publicly traded firms, including Humana Inc. and Elevance Health, Inc., offered better second-quarter performances, but still saw their share prices fall amid investors’ concerns about how medical costs will shake out in the second half. 

Even after health plans were given the option to expand pre-deductible coverage in certain health plans, medication adherence didn’t significantly improve, according to a recent issue brief from the Employee Benefit Research Institute (EBRI). 

Yet while the impact was minimal for most medications, Paul Fronstin, Ph.D., one of the report’s authors, says adherence was already high for the members evaluated, and the majority of insurers introduced copayments and/or coinsurance when expanding pre-deductible coverage.