Spotlight on Market Access

The Trump administration on May 22 revealed multiple initiatives to improve health care price transparency, including updating guidance for health plans to publish data and seeking public input via requests for information (RFIs). Kolton Gustafson, an Avalere Health principal, tells AIS Health the announcements are “very significant for both plans and pharmaceutical manufacturers,” although he notes it is still to be determined whether they will lead to lower prices for health care services and prescription medications.  

The administration said the moves by HHS, along with the Labor and Treasury departments, will strengthen the Transparency in Coverage (TiC) rule, which was finalized in November 2020 and required health insurance companies to publicly post in-network rates, out-of-network allowed amounts and other data, as well as the Hospital Price Transparency rule, which was finalized in November 2019 and required hospitals to publicly disclose gross charges, cash prices, negotiated rates and other information.  

As expected, President Donald Trump signed an executive order on May 12 that would revisit the idea of implementing most-favored nation (MFN) pricing. While the proposal seems to be more extensive than his previous attempts at implementation of the model, it is scarce on details about how the process will go.

In the order, Trump noted that while the U.S. has less than 5% of the population in the world, it “funds around three quarters of global pharmaceutical profits,” an “egregious imbalance…orchestrated through a purposeful scheme” by pharma manufacturers “deeply discount[ing]” their drugs in foreign markets and charging “enormously high prices” in the U.S. to “subsidize” the lower prices outside the country.

In April, New Jersey became the 21st state to sign into law legislation mandating coverage of biomarker testing for state-regulated plans. But gaps still exist in coverage: A recent Zitter Insights survey found that 30% of commercial and Medicare payers do not provide coverage of companion diagnostics — a type of biomarker testing — for their members.

On April 23, New Jersey Lieutenant Governor and Secretary of State Tahesha Way signed A-4163/S-3098 into law, mandating that state-regulated health insurance plans, Medicaid, the State Health Benefits Program and the School Employees’ Health Benefits Program cover “biomarker precision medical testing…for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of a disease or condition, excluding asymptomatic screening, to guide treatment decisions of a subscriber when the test is supported by medical and scientific evidence.”

As fiduciaries, employers must act in the best interests of their employees and plan, but when it comes to biosimilars, some are not fully promoting them over higher-cost, rebatable reference drugs. During a recent webinar hosted by Midwest Business Group on Health (MBGH), employers including United Airlines and Caterpillar Inc. shared details of their successful efforts to move employees onto the cost-saving drugs.

MBGH also unveiled an Employer Action Brief on biosimilars with the same title as the webinar: Improved Adoption of Biosimilars by Employers Matters.

Removing Medicare Part D copay amounts for low-income beneficiaries significantly enhanced medication adherence, according to a Wakely report. As the CMS Center for Medicare and Medicaid Innovation ends the Value-Based Insurance Design (VBID) model later this year, these findings highlight the “compelling need for both state and federal policymakers to explore new strategies or incentives that enable MAOs to continue offering similar benefits” and improve outcomes to members with specific socioeconomic statuses, Wakely observed.

Beginning in 2021, Medicare Advantage plans were allowed to waive Part D cost-sharing amounts for select members through the VBID model. As of 2025, 62 MA organizations are offering that benefit for their Dual Eligible Special Needs Plan (D-SNP) members. D-SNP members who were eligible for the benefit had $0 copays on all covered drugs, through all phases of coverage.