From Health Plan Week - UnitedHealth Group’s $12.8 billion play for the fourth-largest PBM Catamaran has raised concerns over client retention as market specialists question if other health plans — like Cigna Corp. — will reconsider their arrangements with the standalone PBM Catamaran now that it appears it will become part of UnitedHealth’s OptumRx. Read more
From Health Plan Week - Moves by PBMs, in collaboration with health plans, to stomp out what are considered by payers to be overpriced, unnecessary and borderline or actually fraudulent costs tied to compounded drugs has started to dramatically cut accepted claims for pain management, hormone replacement and other uses of these mostly topical creams formulated in special compounding pharmacies. Read more
From Inside Health Insurance Exchanges - At least two private exchange vendors say they have a workaround for federally facilitated exchange (FFE) states if the Supreme Court determines federal subsidies can be distributed only through state-based exchanges (SBEs). Private exchanges could be very helpful to states in providing the “back office” infrastructure and the IT platform needed to operate their own ACA exchanges, says Mark Hall, a professor of law and public health at Wake Forest University. Read more
From Medicare Advantage News - Pharmaceutical costs in Medicaid managed care programs that “carve in” pharmacy benefit management and thus let insurers handle it are 14.6% lower in terms of average net cost per prescription than in “carve-out” Medicaid states, according to a new study done for trade group America’s Health Insurance Plans (AHIP) by consulting firm The Menges Group. The study comes at a time when, as AHIP notes, some additional states are considering… Read more
From Specialty Pharmacy News - A confluence of events within the health care industry in 2014 — many of them tied to specialty medications — made it an exceptional year in many ways. Read more
From Report on Medicare Compliance - For the second time in six months, a hospital has settled a case over alleged violations of CMS provider-based regulations. Hospitals are vulnerable in this area because of the many technical requirements for provider-based status, and CMS in particular is cracking down on shared-space arrangements, lawyers say. W.A. Foote Memorial Hospital, doing business as Allegiance Health in Michigan, agreed to pay $2.635 million in a civil monetary penalty settlement with the… Read more
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