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PBMs Prepare for Big Changes Tied to Part D Rebate Rule

with Chart: Premiums Could Rise, but Cost-Sharing May Drop With New Part D Rule

February 14, 2019

Nearly two weeks after the Trump administration issued a proposed rule that would effectively overhaul the prescription drug rebate system, the dust has still not settled in the PBM sector as firms brace for a seismic shift in how they do business.

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As Cystic Fibrosis Costs Rise, Payers Seek New Strategies

with Chart: Current Market Access to Cystic Fibrosis Medications

February 14, 2019

Payers typically use tools such as prior authorization and utilization review to manage cystic fibrosis treatments. But they are on the cusp of implementing more innovative strategies that might help to improve adherence while addressing the cost of cystic fibrosis drugs, which typically receive orphan-drug status, PBM experts say.

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Express Scripts Cites Record Low Commercial Trend in ’18

February 14, 2019

For its first annual drug trend report as a part of Cigna Corp., Express Scripts Holding Co. said Feb. 6 it had achieved a record low drug trend of 0.4% across its clients’ employer-sponsored commercial plans in 2018. Overall, the PBM reported savings of $45 billion for its clients last year.

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Protected Class Proposal Could Be the Change Part D Needs

February 14, 2019

Medicare Part D plan sponsors since the inception of the Part D program have been required to cover “all or substantially all” drugs in six therapeutic classes, a policy that managed care stakeholders have argued hinders plans’ ability to negotiate discounts and hold down costs in the so-called “protected classes.” Although CMS in 2014 unsuccessfully tried to address this issue by proposing to remove three of the six categories from protected status, the agency may soon finalize a revised policy giving sponsors more leeway to manage these high-cost drugs and save the federal government an estimated $1.85 billion over the next 10 years.

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News Briefs

February 14, 2019

✦ The five largest conglomerates combining health insurance and pharmacy benefits are on track this year to be “bigger than the five preeminent tech companies,” Axios reported Feb. 11. Anthem Inc., Cigna Corp., CVS Health Corp., Humana Inc. and UnitedHealth Group together expect to collect almost $787 billion in 2019, above the combined $783 billion of projected revenue for Facebook, Amazon, Apple, Netflix and Google, Axios said.

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‘Monumental’ Rebate Proposal Sparks Ire From Payers, PBMs

February 11, 2019

While a new federal proposal to overhaul the prescription drug rebate system may not be a significant threat to major managed care companies’ bottom lines, insurers and PBMs alike are still not happy about it. Industry experts say that’s because insurers will likely have to raise Medicare Part D premiums in response, thus hurting their competitive advantage, and PBMs will be forced to rework their business models.

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