Maximum Fair Price and Implications for Payers

Maximum Fair Price and Implications for Payers The Lynchpin of Medicare Price Negotiations under the Inflation Reduction Act (IRA) The Issue at a Glance Maximum fair price (MFP) serves as the foundation of Medicare’s drug price negotiation program. It is the highest price that a Medicare Part D plan sponsor or beneficiary can pay for…

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Specialty Pharmacy Network Disruptors

Specialty Pharmacy Network Disruptors New entrants bring alternatives to standard Pharmacy Benefit Manager networks What is a specialty pharmacy network? Let’s lay some groundwork before we go into “What’s New.” Specialty medications are more than half of the cost of medication spend, and payers are constantly looking for methods to ‘bend the trend,’ control costs,…

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Understanding the future of Copay Maximizers

Understanding the future of Copay Maximizers COPAY MAXIMIZERS – Gone tomorrow? What is a Copay Maximizer? Copay Maximizers are programs deployed by Pharmacy Benefit Managers (PBMs) that allow a payer to capture the pharmaceutical manufacturers’ funding that is designated to offset patient copays and further offset payer costs. This is done by applying the funding…

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Medicare Prescription Payment Plan

Medicare Prescription Payment Plan What is Copay Smoothing and How can Part D Plan Sponsors Prepare? Issue at a Glance Thanks to the Inflation Reduction Act (IRA), the Medicare Part D benefit will undergo a major redesign in 2025. As part of this, all plan sponsors will be required to offer all beneficiaries the Medicare…

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The Volatility of Rebate Management

The Volatility of Rebate Management Rebates Changing Due to Regulatory Pressure and Evolving Drug Market Why does the model need to change? The PBM market is in a state of tremendous fluctuation. We have:payors looking to decouple pharmacy benefit management services (e.g. use of non-verticallyintegrated big 3 PBM models and using claims processing, mail service, etc…

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OBESITY- Is The Treatment an Epidemic

OBESITY- Is The Treatment an Epidemic A white paper about the on & off-label use of the GLP-1 Agonists What is happening with the treatment of obesity? In this white paper, we will dive into the GLP-1 receptor agonists (“GLP-1”) for the treatment of obesity. Although GLP-1s have been used primarily for diabetes, we are…

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Medical or Pharmacy Benefit

Medical or Pharmacy Benefit A white paper on the background of pharmacy vs medical coverage Managing drug spend on both benefits With the pipeline of medications and treatments being largely ultra-expensive medications overwhelmingly infused, injected or through more expansive treatment protocols like gene therapies – decisioning on where to cover these medications is now, more…

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Covid Testing – Does Free Equal Frivolous?

Covid Testing – Does Free Equal Frivolous? A white paper concerns of waste, and coverage change What is Changing, and When? The requirement by the federal government for commercial coverage of COVID-19 tests ends May 11, 2023. While some have stated concern over a potential inability to get the testing once it is no longer…

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Sanofi Joins Lilly and Novo Nordisk to Cut Insulin Prices (Update)

Sanofi Joins Lilly and Novo Nordisk to Cut Insulin Prices (Update) A white paper on what this means to medication cost management What is the Update? Following suit of Lilly and Novo Nordisk, Sanofi announced price decreases and caps on their insulin products that would take effect at the beginning of next year. Price decreases…

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