Drug Coverage

Foluso Agboola discusses the framework that the Institute for Clinical and Economic Review has developed for assessing whether clinical trial populations represent the real-world patient population.

Ozempic and Rybelsus could become a target for Medicare price negotiation because of high spending and additional approved uses of the GLP-1 therapies.

Medicare Part B beneficiaries may save between $1 and $3,575 per average dose for the 41 drugs whose prices have risen higher than inflation.

Medicare and Medicaid will cover Wegovy for its recently approved indication to reduce the risk of cardiovascular death, heart attack and stroke in adults with cardiovascular disease and obesity.

This follows AstraZeneca’s and Boehringer Ingelheim’s announcements to also cap their asthma chronic obstructive pulmonary disease drugs at $35.

Lenmeldy is the first approved gene therapy to treat children with juvenile metachromatic leukodystrophy, a life-threatening inherited disease of the body’s metabolic system.

Zymfentra, with a price of $6,181.08 for two shots over four weeks, is approved as maintenance therapy for adults with ulcerative colitis and Crohn’s disease.

In a recent survey, payers said the Inflation Reduction Act will help lower patients’ out-of-pocket costs, but they were concerned about Medicare’s drug price negotiation and the IRA’s impact on formulary management.

AstraZeneca also said it had reduced the list price of Symbicort beginning Jan. 1, 2024.

The new collaboration gives Prime access to Capital Rx’s secure claims system JUDI, which Capital Rx leaders say was developed with enhanced security protocols.

In 2021, pediatric mental health conditions were associated with $31 billion in child spending and $59 billion in household spending, which made up 46.6% of all pediatric medical spending that year.

Michigan’s state Medicaid agency has signed an outcomes-based agreement for Lyfgenia patients with sickle cell disease. The agreement provides payers with risk sharing tied to vaso-occlusive events-related hospitalizations

Quantile Health is offering a new solution to help small health plans and self-insured employers fund gene therapy access — with a subscription model.

Fran Gregory, Pharm.D., of Cardinal Health, talks about a survey of ophthalmologists and their concerns about using biosimilars for retinal conditions.

Beginning in 2025, people with Medicare Part D drug coverage will have the option to pay out-of-pocket costs in monthly payments spread out over the year.

iDose TR was approved to reduce intraocular pressure in patients with ocular hypertension or open-angle glaucoma. It has a wholesale acquisition cost of $13,950 per dose/implant.

CarelonRx will provide digital coaching and wellness tools and incorporate behavioral and social health screenings for members.

The economy and healthcare costs are the issues voters want to hear about going into the 2024 presidential election, finds a survey by KFF.

Avalere’s Kolton Gustafson talks about CMS’ new model for negotiating outcomes-based agreements for sickle cell gene therapies for patients in state Medicaid programs.

Payers now covering Hadlima include United Healthcare, Prime Therapeutics and associated Blues plans, and some managed Medicare organizations.

Rebates, falling prices, and rebate walls, where drug manufacturers agree to a certain price in exchange for an exclusive contract with payers, limit competition and create a dynamic of misaligned incentives.

The Inflation Reduction Act has helped to close some of the gaps in insurance coverage for vaccines, including some of the newly approved ones.

Voquezna is a potassium-competitive acid blocker, which has a mechanism similar to proton pump inhibitors but with a more rapid action. It has a list price of $650 for a 30-count bottle.

In three states — California, Florida, and Texas — more than 100,000 Part D enrollees exceeded $2,000 in spending on prescription drugs in 2021, finds a new analysis from KFF.

CVS’s Health Services segment — which includes its PBM CVS Caremark — now accounts for more than half of CVS’s total revenue.

Although HHS is no longer managing the distribution of COVID-19 drugs, Secretary Xavier Becerra has been closely monitoring distribution of the antivirals Paxlovid and Lagevrio.

Although most older adults support Medicare coverage of medications for weight loss drugs, only one in three favor paying more in premiums for this coverage, finds University of Michigan survey.

The bulk of Cigna’s $195.3 billion 2023 revenue comes from Evernorth. And Cigna is positioning itself to grow Evernorth even more.

The sale, valued at about $576.5 million, is part of Rite Aid’s restructuring plan after filing for bankruptcy in October 2023.