Spotlight on Market Access
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As Biden Admin Winds Down, Will It Address Accumulators, Maximizers as Promised?
As President Joe Biden’s administration nears its end, two promised rules on copayment accumulators and maximizers have yet to be released. They stand to have a huge impact on whether pharma manufacturer-provided patient assistance — much of which is provided for specialty drugs — must be counted toward patients’ out-of-pocket responsibility.
The first concerns a lawsuit over the 2021 Notice of Benefit and Payment Parameters (NBPP) and its stance toward copay accumulators.
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Study Puts Price Tag on Medicare Coverage of GLP-1s for Obesity
If Medicare Part D covered GLP-1 drugs for obesity, rather than just Type 2 diabetes, it could increase annual spending by $3.1 billion to $6.1 billion, according to a recent Health Affairs study.
The introduction of GLP-1 medications for treatment of diabetes and obesity has reignited the debate over Medicare’s prohibition on covering weight loss medications. In June, the House Ways & Means Committee advanced legislation that would provide a limited pathway for adults 65 and older to get anti-obesity GLP-1s covered by Medicare. The bill has not yet passed the full House.
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Payers Eye Rebate Leverage, UM in Response to Medicare-Negotiated Drug Prices
Now that CMS has revealed the prices of the first 10 drugs subject to Medicare price negotiation, all eyes are on how Part D plans will cover those drugs on their formularies in 2026, when the new prices go into effect.
To that end, a recent poll from Zitter Insights offers some clues about how payers and PBMs are thinking about this thorny question.
The flash poll was conducted after CMS revealed the results of the first round of the Medicare Drug Price Negotiation Program, which was authorized by the Inflation Reduction Act. Through that process, Medicare for the first time set a Maximum Fair Price (MFP) for 10 branded drugs selected due to their high cost and lack of generic or biosimilar competition.
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MMIT Payer Portrait: L.A. Care Health Plan
L.A. Care Health Plan is the largest publicly operated health plan in the United States, serving more than 2.5 million members in Los Angeles County. It largely serves Medi-Cal, the state's managed Medicaid program, but also offers products on California's state-based health insurance exchange, Covered California. In 2022, the insurer launched a Dual Eligible Special Needs Plan (D-SNP) that coordinates both Medicare and Medi-Cal benefits. Additionally, its PASC-SEIU Homecare Workers Health Care Plan is specifically designed for Los Angeles residents working as in-home caregivers. Most recently, L.A. Care in August 2024 cut 24% of its prior authorization codes to help avoid delays in member care and speed up inpatient discharge requests.
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As CMS Releases IRA-Negotiated Prices, Payers Already Have Made Changes
While the Inflation Reduction Act (IRA) had multiple provisions affecting a variety of industries, including energy, agriculture and manufacturing, the prescription drug aspects of the law have arguably gotten the most attention, both positive and negative. While some of those provisions have already gone into effect, today CMS released the eagerly anticipated negotiated prices for the first 10 drugs, which will go into effect on Jan. 1, 2026. But both Medicare and commercial plans have begun to modify their drug management approach in preparation for the law’s potential impact, according to research from Zitter Insights.
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