Spotlight on Market Access
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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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GOP Lawmakers Cry Foul at Part D Stabilization Demo
With the Medicare Part D national average monthly bid amount (NAMBA) set to spike 180% next year, CMS late last month unveiled a new demonstration program aimed at stabilizing a market that is experiencing unprecedented volatility.
However, some Republicans in Congress are up in arms over the demonstration, arguing that it contains “extra-statutory, eleventh-hour policy changes” aimed at cleaning up a problem created by the Biden administration’s most-touted health policy achievement.
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Pharma Can Take Variety of Approaches to Enhance IDN Partnerships
Integrated delivery networks (IDNs) are becoming an increasingly larger stakeholder within the U.S. health care system. As of January 2024, almost 80% of physicians were employees of hospitals/health systems and other corporate entities such as private-equity firms, according to an April report prepared by Avalere Health and commissioned by the Physicians Advocacy Institute. Pharma manufacturers can take steps to enhance their partnerships with these entities, said industry experts at a recent webinar.
The Aug. 8 webinar was sponsored by Eversana, an independent provider of services to the life sciences industry, and presented by print and digital content provider Pharmaceutical Executive, an MJH Life Sciences brand.
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