Pharmacy or Medical Benefit? Specialty Pharmacy Weighs In
The reimbursement and dispensing of specialty pharmacy drugs is made complicated by inconsistencies in coverage, wherein different plans will categorize the same treatment as a pharmacy benefit or a medical benefit. This can determine coverage and therefore where patients will go for medications. In a recent article in Pharmacy Times, Bill Bolgar discusses a comprehensive pharmacy services approach that lets specialty pharmacies categorize drugs into medical or pharmacy benefits.
PBM Gets Ready for Congressional Investigations
The pharmacy benefit manager (PBM) industry is preparing for increased scrutiny from members of the US Congress. Politico recently spoke with JC Scott, CEO and President of the industry’s main lobbying group, the Pharmaceutical Care Management Association, about the industry’s plans going forward. A key sticking point at the moment is the drug pricing reform in the Democrat’s Inflation Reduction Act.
Cash-Only Pharmacy Offers Novel Model to Reduce Drug Prices for Patients
The small-town pharmacy Honest Rx explicitly does not take health insurance, a practice the owner says helps his patients save money on their medicines. The Virginia pharmacist says that dealing with pharmacy benefit managers (PBMs) and payer organizations slows down his practice and separates him from his patients, whom he generally charges wholesale cost + 20% + a dispensing fee.
Moving to a New PBM Model to Change, and Save, the Industry
With pharmacy benefit manager attracting growing public and governmental scrutiny, the industry has to move past current models that hurt patients while lining their pockets. In a new two part article on Forbes, Seth Joseph discusses the issues facing the industry and ways it can move forward to better, more equitable models. Part one explains PBMs and recent problematic shifts in the industry.
OptumRX Settles Ohio Lawsuit for $15 Million
OptumRX has reached a settlement with the US state of Ohio to the tune of $15 million. The suit centered around claims the pharmacy benefit manager (PBM) giant was over-billing the state’s Bureau of Workers’ Compensation. Andrew Krejci, a spokesperson for OptumRX, initially argued that negotiations were ongoing after the settlement was announced by Ohio Attorney General Dave Yost.
FTC Chair Plans to Explore All Options in PBM Investigations
The chair of the US Federal Trade Commission (FTC), Lina Khan, has pledged to use all the tools at her disposal to investigate the practices of pharmacy benefit managers (PBMs), who have recently faced increasing scrutiny. This is due to allegations of anti-competition and price fixing. A formal investigation by the agency was announced this summer.
$14 Million Settlement Reached in Case Between PBM and Largest Managed Care Payer in US
MassHealth has reached a $14 million settlement with the Centene Corporation, a major pharmacy benefit manager (PBM), as announced by the state’s attorney general (AG), Maura Healey. MassHealth is the largest Medicaid managed care payer in the US and has been embroiled in a legal battle with Centene, over claims the company had failed to provide the discounts and rebates it promised to the state, jacking up costs.
FTC puts PBMs and Pharma “On Notice” over Insulin Prices
The US Federal Trade Commission (FTC) has issued a new policy statement saying it will actively target pharmacy benefit managers [...]
US Senate Introduces Bill to Give FTC More Power Over PBMs
A new bill in the US Senate would, if enacted, give the Federal Trade Commission (FTC) more power to control [...]
Ensuring PBMs Provide Value to Improve Care Management
Pharmacy benefit managers are ostensibly intended to help reduce drug costs for payers and patients, but the retail-like volume-based model [...]
FTC Faces Pressure from Pharmacies to Act on High Drug Costs
As the cost of prescription drugs continues to rise, the Federal Trade Commission (FTC) is under increased pressure from independent [...]
Split Vote Blocks FTC Investigation into PBM’s Impact on Pharmacies
A 2-2 vote last week blocked the FTC’s investigation into the impact of pharmacy benefit managers (PBMs) on specialty pharmacies [...]
FTC to Vote on Investigating Pharmacy Benefit Manager Practices
The US Federal Trade Commission (FTC) will vote on whether to examine the impact of pharmacy benefit managers (PBM) on [...]
Centene Pays $28 Million After Fifth State Investigation
The health insurance company Centene agreed to pay the state of Kansas almost $28 million in a settlement after allegations [...]
“Specialty Pharmacy’s Post-Pandemic Outlook” Asembia 2021 Keynote Recap
The future of specialty pharmacy in the post-pandemic world was the topic of the October 27th keynote sessions at Asembia [...]
Role of Pharmacy Benefit Managers Under Congressional Scrutiny
The role of pharmacy benefit managers (PBM) on patient out of pocket prices was examined by a US congressional hearing [...]
What a tangled web we weave: The complex relationship between PBMs and GPOs
Join Avalere Health principal Mike Schneider as he discusses why traditional Pharmacy Benefit Managers (PBMs) are deciding that now may [...]
Paper Looks at Impact of Coverage Policies on Pharma Incentives
A recently-published study by Leila Agha, Soomi Kim and Danielle Li analyzes how insurance coverage policies impact incentives for innovation [...]
Report on PBM Market Forecasts 7% CAGR Between 2019-2025
A new report from Arizton forecasts a compound annual growth rate of 7 percent for the pharmacy benefit management market [...]
PhRMA: PBMs Hamper Access with Expanded Exclusion Lists
In a recent blog post, PhRMA says CVS Caremark and Express Scripts have hampered patient access to a number of [...]
Supreme Court Delays Arguments on Arkansas’s PBM Law
The Supreme Court has pushed back arguments in a case involving an Arkansas law that regulates the rates at which [...]
PBM Report Suggests Wider Use of Tools Can Lead to $1 Trillion in Savings
A new study by Visante, funded by the Pharmaceutical Care Management Association (PCMA), suggests greater use of PBM tools could [...]
Supreme Court to Hear Lawsuit Challenging State’s Authority to Regulate PBMs
The Supreme Court is set to hear a lawsuit filed by the Pharmaceutical Care Management Association which challenges an Arkansas [...]
Article: Stop Putting All the Blame on PBMs
Jack Kemp Foundation's Ike Brannon and DePaul University's Tony LoSasso in a recent article published on Bloomberg Law say pinning [...]
