Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Prescription Drug Rates

Medicare Advantage Part B Plans Can Use Drug Step Therapy

August 13, 2018 - CMS is allowing Medicare Advantage (MA) health plans to implement step therapy protocols in order to decrease prescription drug spending. On January 1, 2019, MA health plans can apply step therapy guidelines for physician-administered medications. Step therapy requires beneficiaries to use condition-based prefered medications before using more expensive drugs. MA plans can also...


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Generic Drugs Could Have Saved $3B for Medicare Part D Program

by Thomas Beaton

Using generic drugs instead of their brand-name equivalents could have saved the Medicare Part D program approximately $3 billion in 2016 alone, according to new data from HHS. A relatively small number of brand-name therapies is...

BCBSA Adds Opioid Abuse Accreditation to Treatment Facilities

by Thomas Beaton

The BlueCross BlueShield Association has announced a new accreditation program for opioid abuse treatment centers as a larger part of the organization’s mission to combat the US opioid crisis. In 2013, only 22 percent of treatment...

CMS Proposes Drug Pricing, Price Transparency Changes for Medicare

by Thomas Beaton

CMS has proposed a series of policy changes for Medicare that would promote prescription drug affordability within Medicare, and has also requested stakeholder comments about ways to improve price transparency for Medicare services. As...

CMS Approves Okla. Value-Based Drug Purchasing for Medicaid

by Thomas Beaton

CMS has approved the nation’s first value-based drug purchasing agreement for Medicaid by allowing Oklahoma’s state program to negotiate supplemental prescription drug rebates based on treatment outcomes. CMS allows state...

Private Payers Deny Hepatitis C Drug Coverage to 52% of Members

by Thomas Beaton

Private payers denied Hepatitis C drug coverage to 52.4 percent of commercially insured beneficiaries from 2014 to 2017, according to new research from the Perelman School of Medicine at the University of Pennsylvania. Hepatitis C drug...

MN Law Allows Some Patients to Override Payers on Step Therapy

by Thomas Beaton

Minnesota Governor Mark Dayton has signed a bill into law that allows patients and providers to execute overrides on payer step therapy programs for prescription drug treatments in certain clinical situations. HF 3196 requires payers to...

CMS: Medicare Part D Gag Clauses are “Unacceptable”

by Thomas Beaton

CMS Administrator Seema Verma has stated in a letter to health plan sponsors that CMS will no longer tolerate Medicare Part D gag clauses as the federal agency continues to promote prescription drug price transparency for...

CMS Highlights Drug Price Transparency Data Dashboards

by Thomas Beaton

CMS has released redesigned drug price dashboards to provide information about manufacturer drug costs and advance the agency’s goals of promoting consumer price transparency. Patients, providers, and researchers are able to explore...

Payers Express Enthusiasm for Prescription Drug Pricing Reforms

by Thomas Beaton

Healthcare payers and associated trade groups have expressed enthusiasm about President Trump’s proposed prescription drug pricing reforms.   A number of influential organizations have offered commentary on the plan, including...

CVS Health Offers New Tools for Lowering Prescription Drug Costs

by Thomas Beaton

CVS Health has launched new cost-saving initiatives that aim to lower beneficiary prescription drug costs through co-pay adjustments, pricing transparency technology, and increased promotion of generic drugs. The initiatives follow a CVS...

BCBS Association: Use Alternative Pain Therapies Before Opioids

by Thomas Beaton

The BlueCross BlueShield Association (BCBSA) has announced a new professional standard that removes opioid prescriptions as a primary pain treatment in a majority of clinical situations. The payer’s National Council of Physician and...

Aetna Will Apply Pharmacy Rebates to Prescription Drugs in 2019

by Thomas Beaton

Aetna has announced plans to automatically apply pharmacy rebates to eligible prescription drug benefits by 2019 in an effort to increase pricing transparency and control costs. Nearly three million Aetna members are likely to experience...

Payers Address Opioid Safety Via Education, $0 Narcan Co-Pays

by Thomas Beaton

Commercial payers are addressing the nation’s opioid crisis and promoting opioid safety by funding patient education programs and waiving Narcan co-pays to reduce barriers to access. Patient-centered strategies have allowed payers...

96% of Payers Are Committed to Electronic Prior Authorization

by Thomas Beaton

The vast majority of payers are committed to implementing electronic prior authorization solutions as a way to address administrative problems with prior authorization procedures, according to research published through the ePA National...

AHIP: 25% of Opioid Prescriptions Top CDC Dosage Guidelines

by Thomas Beaton

An AHIP retrospective analysis of claims data found that 25 percent of opioid prescriptions were above CDC dosage recommendation and provides a basic snapshot of problematic areas where payers could minimize patient safety risks related to...

GAO: CMS Needs More Data to Manage Medicare Opioid Risks

by Thomas Beaton

The Government Accountability Office (GAO) has recommended that CMS should collect additional data on Medicare beneficiary opioid risks, including the number of beneficiaries with high-dose opioid prescriptions, the number of providers...

Payers, Providers Pledge to Improve Prior Authorizations

by Thomas Beaton

AHIP, BCBSA, AHA, and other leading payer and provider organizations announced an industry pledge to improve the efficiency of prior authorizations while reducing administrative burden. Leaders of organizations participating in the pledge...

Payers Leverage Data, Wellness Benefits to Address Opioid Abuse

by Thomas Beaton

Providing substance use disorder (SUD) treatment options and making investments in beneficiary drug safety is a critical component of wellness programs, considering that the White House deemed opioid abuse a public health emergency in...

Outcomes-Based Contracts Offer Payers New Pharmaceutical Options

by Thomas Beaton

Payers may be more willing to provide their beneficiaries with genetic drug therapies that costs hundreds of thousands of dollars if they enter into outcomes-based pharmaceutical contracts that lessen financial risks. An outcomes-based...

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