PBMs

Federal legislation on PBM reforms has stalled, but state efforts remain active. Illinois’ Healthcare Protection Act includes several other limits on insurer power, including prohibiting prior authorization for inpatient mental health care.

Dramatic transformation in the US Medicare Part D benefit design does not require any changes to CMS’ overall approach to reviewing formulary submissions from private drug plan sponsors, the agency says in its final guidance implementing the design changes for 2025.

Infographic details who gave what to whom as all segments of the US healthcare industry gear up for the presidential election cycle.

The well-known businessman and TV personality told the White House that the US needs to ‘stop doing business with the big three PBMs,’ helping to fight the drug industry’s battle against the middlemen with a friendlier face not associated directly with the brand industry.

PBM reform isn’t expected to ride along with the next government funding packages, which could push any prospect of legislative reform closer to 2025. Meanwhile FTC says it is facing difficulty getting all the information for its investigation. 

Three-agency guidance, issued as Biden administration is hoping to emphasize reproductive rights in its reelection campaign, outlines the narrow set of circumstances in which a health plan doesn’t have to fully cover certain types of birth control.

The ball is now in the federal government’s and state insurance commissioners’ courts to enforce a district court ruling after HHS stops its appeal. As groups that brought the suit press CMS for guidance, they also eye complaints with DOL and class-action suits.

CEOs of J&J, Bristol Myers Squibb and Merck comment on the status of legislative policies reforming pharmacy benefit manager practices and the likelihood they will lower out-of-pocket costs for patients at a recent Senate hearing.

The payor’s multiyear plan to ditch the traditional PBM model and use multiple vendors has drawn a lot of skepticism from other actors in the health care system, but Blue Shield is hoping that it can help give policymakers some momentum, VP Lum tells the Pink Sheet.