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.

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.

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.

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.