pharmacy benefit managers

Inflated savings, hidden costs: How vendors who “carve-out” specialty benefits fail to deliver promised value

In recent years, a number of niche vendors have entered the market, promising significant savings for payers if they “carve-out” specialty pharmacy services from integrated pharmacy benefits management (PBM). While the savings they claim to provide sound undeniably attractive, they are often greatly exaggerated.

CMS finalizes new rules for ACA exchanges in 2022: 5 key provisions

CMS has adopted several new rules that will change how the Affordable Care Act exchanges operate next year. These include rules that will lower out-of-pocket consumer spending by $400 and widen eligibility for gaining health coverage outside of the designated ACA open enrollment period.

Centene refutes Ohio AG’s lawsuit, says it reflects misunderstanding of Medicaid billing

Centene has rebutted the accusations made in a sealed lawsuit filed by the Ohio attorney general that accused the insurer of over-billing the state’s Medicaid department. The lawsuit is based on a misunderstanding of how Medicaid billing operates and should be unsealed, Centene said.

Centene’s “corporate greed” led it to allegedly overcharge Ohio’s Medicaid department

The Ohio attorney general has filed a lawsuit alleging that a Centene subsidiary, which provides Medicaid services in the state, hired multiple companies to administer pharmacy benefits in order to inflate costs. As a result, the state’s Medicaid department paid millions in overcharges.

New insulin report highlights how incentives benefit middlemen, harm patients

The Senate Finance Committee has released a new report detailing findings of their investigation into the role that market dynamics play in the pricing of insulins. The report conclusions further solidify what we already know: perverse incentives in the market drove up insulin costs for patients. Some key details. Many insulins have experienced significant net …

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Key facts: The final rebate rule will be a positive change for patients

While drug middlemen are making billions of dollars in record profits at a time when millions of Americans are facing financial struggles, they are also suing to block the final rebate rule, a policy to lower out-of-pocket drug costs for patients. The fact is that the final rebate rule is a good policy for patients …

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Study finds middlemen excluded nearly 850 medicines from formularies this year

A new study from Xcenda finds that from 2014 to 2020, the number of medicines excluded by at least one of the three largest pharmacy benefit managers (PBMs) from their standard formularies increased by an average of 34% per year. As a result, each year hundreds of thousands of patients with commercial insurance may not …

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PBM Startup Capital Rx Starts Prescription Drug Pricing Shake-Up with Walmart Partnership

By JESSICA DaMASSA, WTF HEALTH A startup PBM? Partnered up with Walmart to bring “everyday low prices” to prescription drug pricing? Is this too good to be true? A.J. Loiacono, founder & CEO at Capital Rx, gives us a quick primer on “Pharmacy Benefit Managers” (PBMs) and why they’ve become known for the element of …

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