Radar on Drug Benefits

In a newly proposed rule, the Biden administration builds upon guidance it released earlier this year and requires private health insurers, for the first time, to cover over-the-counter (OTC) birth control. That includes Opill (norgestrel), which in 2023 became the first daily oral contraceptive approved for use in the U.S. without a prescription. 

The news that insurers will be required to cover OTC birth control did not come as a surprise, as CMS in October 2023 released a request for information (RFI) asking for input about the “benefits and challenges” that would be associated with requiring coverage of OTC preventive products, including contraception.  

On the same day that the Biden administration proposed a rule that would require health insurers to cover over-the-counter birth control, it released a less-heralded guidance document that makes another significant change in coverage policy: Insurers will now have to cover all forms of pre-exposure prophylaxis (PrEP) for the prevention of HIV.  

“It was of major, major significance, because up until right now, plans have been able to satisfy the requirements just by covering one of the [PrEP] drugs,” says Carl Schmid, executive director of the HIV+Hepatitis Policy Institute. 

Only 27% of stand-alone Medicare Part D Prescription Drug Plans (PDPs) — or 11 contracts — earned 4 stars or higher for the 2025 plan year, according to CMS’s 2025 Medicare Advantage and Part D Star Ratings. The 2025 Star Ratings also resulted in nine contracts receiving 2.5 stars or lower, compared with six in 2024, and the average overall rating for PDPs dropped from 3.34 to 3.06.

About 4.5% of all PDP members are enrolled in contracts that earned 4 stars or higher in 2025, a steep decline from 23.5% of members in 2024. CMS unprecedentedly recalculated the 2024 Star Ratings after two federal judges agreed there were flaws in the initial calculation.

A Medicare Part D policy forbidding plan sponsors’ formularies from excluding nearly all drugs in six “protected” classes hinders payers’ ability to negotiate prices and may lead to significantly higher costs to the health care system, according to a recent analysis published in Health Affairs. The study’s lead author notes this is the first peer-reviewed trial suggesting Part D plans “can’t negotiate as high of rebates as they might otherwise be able to” for drugs in the protected classes. 

The protected class regulation has been in place since the Part D program began in 2006 and applies to anticonvulsants, antidepressants, antineoplastics, antipsychotics, antiretrovirals and immunosuppressants for treatment of transplant rejection. Combined, medications in those classes accounted for nearly one-quarter of drug spending in Part D in 2021, the researchers noted. 

A recent report from CVS Health Corp. shows that people place great trust in their local pharmacists and prefer in-person interaction. It also emphasizes the role of pharmacists in communities and the importance of their work beyond filling prescriptions, including administering vaccines. But the report comes at a time when CVS is facing significant turmoil, including ongoing store closures and the recent ouster of former CEO Karen Lynch. 

The main purpose of the report and its timing could be for CVS to expand the roles of its retail pharmacists to strategically grow the company’s place on the health care delivery chain, says Ge Bai, Ph.D., a business and health policy professor at Johns Hopkins University.