FTC Settles With Cigna’s Express Scripts
The Federal Trade Commission (FTC) and Cigna’s Express Scripts pharmacy benefits manager (PBM) reached a settlement that resolves allegations that the PBM artificially drove up prices for insulin. Cases continue against CVS Caremark and OptumRx.
Express Scripts will implement a number of reforms, including:
- It will stop listing preferred drugs at the high wholesale acquisition cost rather than lower cost versions on its standard formularies.
- It will no longer omit drugs with a low per-unit list price on formularies or give preferential treatment to those with a high list price.
- It will offer access to Trump Rx’s direct-to-consumer platform as part of its standard offerings. Costs will count toward Express Scripts members’ deductibles.
- It will establish a standard offering for plan sponsors where the out-of-pocket costs for patients are based on the net cost of a drug, rather than the list price.
- It will provide full access to its Patient Assurance Program to all individuals if insulin is on a formulary unless the plan sponsor chooses to opt out.
- It will offer a standard benefit design that allows plan sponsors to transfer off of rebates or spread pricing, and delinking drug manufacturers’ payouts from list prices in standard benefits.
- It will ensure employers do not pay higher than a drug’s net cost.
- It will pay pharmacies the cost of drugs plus a dispensing fee.
- It will reshore its group purchasing organization, Ascent, from Switzerland to the United States.
- It will increase transparency, including reporting more data on drug spending and disclosing any kickbacks to brokers that help employers choose PBMs.
- It will expand access to its patient assistance program’s insulin benefits.
The FTC expects the settlement to lower out-of-pocket costs for drugs by $7 billion over a decade.
Additional articles: https://www.fiercehealthcare.com/regulatory/ftc-evernorth-near-settlement-case-over-insulin-prices and https://www.healthcaredive.com/news/express-scripts-ftc-reach-settlement-insulin-lawsuit/811369/ and https://www.beckerspayer.com/legal/ftc-deal-over-insulin-prices-forces-cignas-express-scripts-to-overhaul-policies/
(Some articles may require a subscription.)
#pbms #drugpricing #employers
https://www.modernhealthcare.com/insurance/mh-cigna-express-scripts-ftc-pbm-lawsuit
CMS Hypes ACO Growth And Potential
The Centers for Medicare and Medicaid Services (CMS) issued a fact sheet regarding latest statistics around Medicare Accountable Care Organizations (ACOs). As of January 2026, 14.3 million Medicare beneficiaries are estimated to receive care coordinated by ACOs, up from 13.7 million in 2025 or a 4.4% increase. This includes those in Medicare Shared Savings Program ACOs and entities participating in innovation accountable care and other models.
In Performance Year 2024, the most recently reconciled performance year, Shared Savings Program ACOs earned shared savings totaling $4.1 billion and saved Medicare $2.5 billion.
The total number of ACOs participating in the Shared Savings Program for Performance Year 2026 is 511, up from 476 ACOs participating in 2025. The organizations had more than 700,000 healthcare providers and organizations and will serve 12.6 million people a 12.3% increase from 2025.
The ACO REACH Model has 74 ACOs with 125,909 healthcare providers and organizations providing care to an estimated 1.7 million people with Traditional Medicare. This model has 614 Federally Qualified Health Centers, Rural Health Clinics, and Critical Access Hospitals participating in 2026.
#acos #apms #medicare #cms
Could ICHRAs Feel The Heat Of High Premiums?
Interesting article on the status of health reimbursement ICHRAs. While advocates remain bullish on the program, which is meant to reduce employer costs by allowing businesses to pay for individual coverage on the Exchanges, it could be that premiums have risen so much that fewer employers may see ICHRA as advantageous. As one example: rate increases on the individual market outpaced premium hikes in the group market on average this year. This undercuts the value proposition – savings are simply not as much.
(Article may require a subscription.)
#ichras #hsas #exchanges #employercoverage
https://www.modernhealthcare.com/insurance/mh-ichra-market-aca-premiums-subsidies
Shadow Medicaid Networks
A new study published in Health Affairs will fire up regulators and Capitol Hill on provider networks in managed care. The study finds that more than one-fourth of doctors enrolled in Medicaid didn’t actually deliver care to any Medicaid beneficiaries in 2021. Almost 28% of doctors enrolled in Medicaid were “ghost providers” and didn’t treat a single patient that year. Another 10% treated fewer than 10 patients.
#medicaid #networks #managedcare
https://www.healthcaredive.com/news/medicaid-ghost-providers-study-health-affairs/811261
Humana Reports Success Of VBC Payments
A new Humana report says there was a 24.3% decrease in inpatient admissions, or a 229,000-stay dip, for Medicare Advantage (MA) members in value-based care arrangements versus those in traditional Medicare in 2024. MA members in value-based care arrangements also see 7.6% fewer inpatient admissions compared to those in non-value-based care MA arrangements. Humana estimates $12.8 billion in savings due to MA value-based arrangements.
#medicareadvantage #medicare #vbc
Exchange Compromise May Be Near Dead
Reports from Capitol Hill suggest that the compromise to extend enhanced Exchange subsidies in some form is near dead. There is little optimism about a compromise being agreed to. Democrats say most of the GOP caucus has no appetite to extend the subsidies. In addition, there is a continuing dispute on abortion coverage, with Democrats unwilling to move from the current laws on coverage. Both GOP Senators Bernie Moreno, R-OH, and Susan Collins, R-ME, have admitted talks have collapsed.
#exchanges #healthcare #coverage
https://thehill.com/policy/healthcare/5723559-moreno-collins-proposal-fizzles
— Marc S. Ryan
