Member: RADAR on Drug Benefits

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Congress to PBMs: Help Fix Drug Prices or Face Consequences

April 11, 2019

On April 9, the same day that Attorney General William Barr clashed with the Democratic-led House Appropriations Committee over the Mueller report, another long-awaited showdown occurred in the Senate. Five executives from the nation’s largest PBMs testified before federal lawmakers — the former trying to underscore their value as middlemen, the latter pushing for more transparency in PBMs’ negotiating process with pharma manufacturers.

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PBMs Sound Off on Proposed Drug Rebate Rule, CMS Memo

April 11, 2019

One day before executives from the country’s largest PBMs testified on Capitol Hill about rising drug prices (see story, p. 1), the trade group that represents them told the Trump administration in no uncertain terms that its proposal to upend the drug rebate system will do more harm than good. The proposed rule in question, released on Jan. 31, would remove safe-harbor protections under the federal anti-kickback statute for rebates paid by drug manufacturers to PBMs, Part D plans and Medicaid managed care organizations, and it would create a new safe-harbor protection for point-of-sale drug discounts (RDB 2/14/19, p. 1). Comments regarding the proposed regulation were due April 8.

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CMS Finalizes Medicare Rates, Unveils ’20 Opioid Policies

April 11, 2019

CMS on April 1 released its annual payment information and policy updates for Medicare Advantage, MA Prescription Drug (MA-PD) and stand-alone Prescription Drug Plans, underscoring the need for a better approach to opioid monitoring and management — including improving access to opioid-reversal agents. Yet overall, industry experts say perhaps the most eye-catching features of CMS’s 2020 MA and Part D Rate Announcement and final Call Letter are the better-than-anticipated pay rate and the lack of worrisome new mandates, policy changes or major technical issues.

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Will WellCare Follow Centene in Cutting PBM Ties With CVS?

April 11, 2019

Though the addition of WellCare Health Plans Inc. — which Centene Corp. aims to acquire in a $17.3 billion deal by the first half of 2020 — could boost Centene’s move to transform its PBM services, the executives of the two companies are remaining coy about their specific plans. For Centene itself, the strategy is clear: the Medicaid managed care giant “has already given notice to CVS [Health Corp.] on moving its PBM in-house,” Credit Suisse analyst A.J. Rice pointed out in a research note to investors.

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Integrated Delivery Networks’ Impact Extends to PBM, Specialty Pharmacy Sectors

April 11, 2019

by Jinghong Chen
Integrated delivery networks (IDNs) — providers that align to form united contracting entities — are experiencing a new wave of influence. The proliferation of accountable care arrangements and the increasing significance of site of care in coverage decisions are primary factors behind this tsunami. For payers, IDNs are prize features in provider networks, and many IDNs contain their own licensed health insurance arm; IDN payers now cover 11% of U.S. medical lives. As such, IDNs rely on either owned or contracted pharmacy benefit managers and specialty pharmacy providers to serve members.

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