Drug Coverage

Judi Health redefines health benefit management with a $400 million funding boost, enhancing transparency and efficiency for employers and health plans.

Optum Rx has increased brand drug reimbursement minimums for 2,300 independent pharmacies that are not its network.

Providers also have concerns about being able to stock certain medications, which would have a negative impact on their patients, according the Avalere Health survey.

Two separate analyses in Health Affairs find the One Big Beautiful Bill creates a loophole that exempts or delays orphan drugs — many of them blockbuster drugs that generate billions of dollars in sales — from price negotiations.

ICER’s comparative effectiveness and value review of Wegovy, Zepbound and oral semaglutide finds they are highly effective treatments with significant health benefits, but affordability and long-term management are still unresolved.

In separate announcements, Form Health and 9amHealth said they would provide patients seeking support for obesity care with nutrition and lifestyle support, as well as prescriptions for medications.

A new Business Group on Health survey finds that nearly a quarter of all employer healthcare spending (24%) went to pharmacy expenses in 2024, and employers forecast an 11% to 12% increase in pharmacy costs heading into 2026.

The biosimilar will be available to any licensed specialty pharmacy in the United States at a 95% discount from Stelara, starting January 1, 2026.

A new study finds Medicare beneficiaries are facing higher deductibles and cost-sharing requirements following changes implemented by health plans as a result of the Inflation Reduction Act.

To help Medicare plans better manage members with high drug expenses, Prime Therapeutics has launched an AI-driven tool to help plans identify members likely to experience increases in pharmacy costs.

Managing specialty and cancer drugs, as well as the GLP-1 therapies, tops the list of priorities this year and next, according to a survey by the International Foundation of Employee Benefit Plans.

Two PBMs, True Rx Health Strategies and Capital Rx, are using pharmacogenomics — how a person’s DNA affects their response to medications — to reduce the trial-and-error of prescribing medications, saving employers and patients time and money.

Health policy researcher Geoffrey Joyce argues that only delinking compensation from the list price of a drug will lower drug spending.

Following in the footsteps of other pharmaceutical companies, Bristol Myers Squibb and Pfizer are offering Eliquis for cash-paying patients at a discount of 40% off the list price.

Optum Rx officials said they now have eliminated reauthorization requirements for more than 140 chronic disease medications.

A separate Prime analysis, however, of year-over-year claims data for Wegovy and Zepbound only found an improvement in adherence in 2024, suggesting there is an evolving understanding of obesity treatment.

More than 50 insurers have pledged to streamline and simplify the prior authorization process through six new commitments.

The FDA had resolved the shortage of Wegovy in April, and telehealth providers were advised to stop selling compounded semaglutide products. Novo Nordisk said that Hims & Hers continues to offer these compounded drugs.

A survey by PSG has found that the pressure to control drug costs is leading some payers to look into unbundling pharmacy benefits as a way for better control.

The pharmacy benefit manager (PBM) industry is under pressure to shift to models that avoid conflicts of interest and misaligned incentives.

State efforts are aiming to bring more disclosure and transparency to PBM practices, mandating certain pharmacy reimbursement levels, requiring 100% pass-through rebates, and prohibiting spread pricing.

Pharmacy costs and outpatient facility care generate 69% of the cost increase for 2025, according to Milliman’s recent Medical Index.

Health plan sponsors are also expected to see a reduction in the net cost per prescription of GLP-1 medications to treat obesity.

A new law in Iowa, if signed by the governor, will mandate 100% pass-through of rebates, increased financial transparency, and a minimal payment for pharmacies. Critics say it will be the most costly mandate in the state’s history.

It could improve access to community pharmacies and lower prices. Or it will limit access to critical drugs and impact payers’ ability to contract for a broad range of services. Industry leaders are unsure about the impact of Arkansas’ law banning PBMs from owning pharmacies.