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From Specialty Pharmacy News - As payers grapple with coverage of the $14,000+ per-year PCSK9 inhibitors, Harvard Pilgrim Health Care has unveiled an exclusive deal with Amgen Inc., which manufactures Repatha (evolocumab). The FDA approved the cholesterol-lowering drug in September (SPN 9/15, p. 10), only a month after it OK’d another PCSK9, Sanofi/Regeneron Pharmaceuticals, Inc.’s Praluent (alirocumab) (SPN 8/15, p. 1). Read more

From Health Plan Week - Health insurers are touting the success of their value-based care arrangements for 2016 in which providers and plans work together on unique offerings both for individual consumers on and off public exchanges and group markets. But at the same time, value-based care proponents question if these efforts will really have an impact on the overall cost and reimbursement structure that continues to bedevil the health care system. Read more

From Inside Health Insurance Exchanges - As part of a 2014 undercover investigation, 11 out of 12 fictitious insurance exchange applications easily glided through the eligibility verification process. On Oct. 23, less than 10 days before the 2016 open-enrollment period began, federal investigators told a House subcommittee that fraudulently obtaining coverage and federal subsidies hasn’t gotten any more difficult. Read more

From Medicare Advantage News - Both Medicare and Medicaid managed care insurers and their trade groups are stepping up verbal attacks on what they consider as excessive increases in prescription drug costs in recent months. Read more

From Specialty Pharmacy News - Media reports about Valeant Pharmaceuticals International Inc. and the business practices of pharmacy Philidor Rx Services LLC have put specialty pharmacies in the spotlight — but not in a good way. Read more

From Report on Medicare Compliance - Hospitals and physicians again have a foot in the door for short inpatient stays because of a new exception to the two-midnight rule in the final 2016 outpatient prospective payment system (OPPS) regulation issued on Oct. 30. However, if they use the new exception liberally, hospitals may find themselves back in the crosshairs of the recovery audit contractors (RACs). Read more

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