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An Update to M3P Guidance and Readiness Medicare Prescription Payment Plan (M3P)

Industry Insights What has new guidance shared and what are PBMs and Vendors doing? The Issue at a Glance It’s time to take another look into the expectations of the Medicare Prescription Payment Plan, otherwise known as M3P or copay smoothing, with the release of additional guidance and more detail now available from PBMs and…

Maximum Fair Price and Implications for Payers

Industry Insights 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 a drug selected for negotiation.…

Specialty Pharmacy Network Disruptors

Industry Insights 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, and manage…

Understanding the future of Copay Maximizers

Industry Insights 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 to their accumulators and…

Medicare Prescription Payment Plan

Industry Insights 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 Prescription Payment…

The Volatility of Rebate Management

Industry Insights 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-vertically integrated big 3 PBM models and using claims processing, mail service, etc from…

OBESITY- Is The Treatment an Epidemic

Industry Insights 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 focused on the recent…

Medical or Pharmacy Benefit

Industry Insights 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 than ever,…

Covid Testing – Does Free Equal Frivolous?

Industry Insights 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 free under all insurances, payers…

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

Industry Insights 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 would reduce list prices for Sanofi’s Apidra by 70%…

New Biosimilar for Macular Degeneration and Retinopathy | AFLIBERCEPT (Eylea)

Industry Insights Medication Update New Biosimilar for Macular Degeneration and Retinopathy Although we hear the word biosimilar commonly now in medication management, the biosimilars coming to market stretch well beyond the new biosimilar for Humira. Disease treatment moved from the use of chemical compounds to biologics years ago, and now with patent expiration, we are…

Network Audit – Results vs Remedies

Industry Insights A white paper on pharmacy audit & investigations Understanding your audit and investigative program – is it working for you? In many cases, we see our audit and investigative reports and check a box that our vendors are managing the network and preventing Fraud, Waste, and Abuse (FWA). Running a tight network audit…

New Oral Option for patients with Anemia due to CKD on Dialysis | Jesduvroq

Industry Insights Medication Update New Oral Option for patient with Anemia due to CKD on Dialysis On February 1, 2023, the FDA approved GlaxoSmithKline’s oral therapy, Jesduvroq (daprodustat), for the treatment of anemia due to chronic kidney disease (CKD) on dialysis.1 Notably, sources estimate that over 500,000 patients of the 700,000+ with end-stage CKD meet…

Lilly and Novo Nordisk to cut insulin Prices

Industry Insights A white paper on what this means to medication cost management What was the change? Both Lilly and Novo Nordisk have announced that their companies will reduce the price of several branded insulin products by as much as 75%. Novo’s decision on March 14th followed closely after Eli Lilly’s earlier announcement on March 1st to…

Manufacturer Funding Changes & Challenges

Industry Insights A white paper on the opposing thoughts on patient assistance What is happening in the world of manufacturer funding assistance? We previously wrote a white paper on the ups and downs of manufacturer funding assistance – read that article on our Industy Insights section of PayerAlly.com. Now, we are taking another step to…

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