Prescription Drug Spending

FDA approval of Wegovy expands coverage access for Medicare beneficiaries

April 24, 2024 - Following new FDA approvals for Wegovy, one in four Medicare beneficiaries with obesity may gain coverage access to the drug to reduce the risk of heart attacks and stroke, according to KFF data. The FDA’s approval of using Wegovy to combat the risk of heart attacks and stroke in people with cardiovascular disease who are overweight or obese...

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Provider markups on specialty drugs increased commercial premiums

by Victoria Bailey

Provider markups on specialty drugs increased 2024 commercial health insurance premiums by $13.1 billion, according to research from Oliver Wyman commissioned by AHIP. Provider-administered drugs can...

GAO: states enact own regulations to address pharmacy benefit managers

by Victoria Bailey

States have implemented their own regulations to address pharmacy benefit manager (PBM) operations, some of which may prove better routes than national legislation, according to a report from the...

Biosimilar competition did not reduce out-of-pocket spending, study finds

by Victoria Bailey

Biosimilar competition did not lower out-of-pocket spending on biologics for commercially insured individuals, a study published in JAMA Health Forum found. Prescription drug spending in the United...

Medicare spending on GLP-1 drugs reached $5.7 billion in 2022

by Victoria Bailey

Medicare spending on GLP-1 drugs, including Ozempic, surpassed $5 billion in 2022 and is likely to continue growing as coverage expands, according to a KFF analysis. GLP-1 drugs Ozempic, Wegovy, and...

Utilization Restrictions on Medicare Part D Drugs Increased, Study Finds

by Victoria Bailey

Utilization restrictions on Medicare Part D drugs, including prior authorization and formulary restrictions, increased over time between 2011 and 2020, according to a Health Affairs study. Pharmacy...

How Payers and Pharmacy Benefit Managers Work Together to Lower Costs

by Victoria Bailey

As prescription drug spending rises in the United States, healthcare stakeholders and policymakers constantly look for ways to curb costs. Many payers turn to pharmacy benefit managers (PBMs), which aim to negotiate lower drug prices with...

Medicare Part D Low-Income Subsidy Loss Tied to Higher Out-of-Pocket Costs

by Victoria Bailey

Beneficiaries who temporarily lost their Medicare Part D low-income subsidy experienced higher out-of-pocket drug costs and fewer prescription fills, a study published in JAMA Health Forum...

US Drug Prices Are 8x the Cost in Peer Countries for Some Drugs

by Kelsey Waddill

Despite efforts to reduce drug costs through Medicare negotiation for 10 common medications, the US still pays more for these drugs than almost any other nation, even after factoring in discounts and...

2022 National Healthcare Spending Growth Slowed to Pre-COVID Levels

by Kelsey Waddill

In 2022, national health expenditures hit $4.5 trillion, a 4.1 percent increase, with a couple of key spending areas seeing growth rates return to pre-pandemic levels, CMS announced in a fact...

Top Reasons Behind Retail, Medicare Advantage Plan Partnerships

by Kelsey Waddill

Payers such as UnitedHealthcare, Priority Health, and Anthem have pursued Medicare Advantage plan partnerships with retail companies. What is the attraction to this type of partnership? Plans that are co-branded with retail companies are...

How Do Rebates Impact Part D Spending for Plans, Beneficiaries?

by Victoria Bailey

While rebates may lower Medicare Part D spending for plan sponsors, they do not reduce drug costs for Medicare beneficiaries, a study conducted by the US Government Accountability Office (GAO)...

Medicare Part D Patients with HIV May See Lower Drug Costs Under IRA

by Kelsey Waddill

The Inflation Reduction Act’s Medicare Part D redesign may improve affordability for beneficiaries with HIV, but stakeholders will need to take steps to ensure beneficiaries get the most out of...

HHS Releases First 10 Drugs Eligible for Medicare Price Negotiation

by Victoria Bailey

Updated 10/3/2023: This article has been updated to include the drug companies' decisions to participate in the negotiation process. HHS has announced the first ten drugs that will be available...

CMS Announces Monthly Payment Option for Out-of-Pocket Part D Costs

by Victoria Bailey

CMS has released draft guidance detailing a new program allowing Medicare beneficiaries to pay out-of-pocket Part D costs in monthly installments. The Medicare Prescription Payment Plan is required...

Blue Shield of CA Launches Value-Based Pharmacy Model to Lower Drug Costs

by Victoria Bailey

Blue Shield of California (Blue Shield) has launched a value-based pharmacy model to improve member access to affordable prescription drugs. The payer has partnered with five companies to deploy the...

Payer Turns to PBM Coupon Program to Lower Prescription Drug Spending

by Kelsey Waddill

Reducing drug prices is top-of-mind for payers and employers alike. Some payers, like Capital Blue Cross, seek to make drugs more affordable by connecting members with existing coupon...

Consumers Blame Payers, Utilization Management for Delays in Care

by Kelsey Waddill

Consumers do not agree that insurers are protecting them from high out-of-pocket costs and find that utilization management practices—such as prior authorization and formulary...

Common Utilization Measures That Impact Value-Based Care Efforts

by Kelsey Waddill

Quality and quantity have a nuanced relationship in the healthcare system: put simply, payers want to reduce members’ quantity of low-value services while increasing the number of services that produce better quality...

10 Top-Selling Drugs Accounted for 22% of Medicare Part D Spending

by Victoria Bailey

The ten top-selling prescription drugs accounted for more than 20 percent of total gross Medicare Part D spending in 2021, a KFF analysis revealed. Under the Inflation Reduction Act’s Medicare...

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