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WSJ Finds Excess Rx Refills At Medicare Plans Via Mail Order

Many argue The Wall Street Journal has it out for health plans as it has had many hard-hitting investigations of fraud and bad practices over the past year or so. Some parts of the industry have accused the Journal of being wrong or behind the times, but the newspaper seems to constantly find scandal afoot, especially among the big national plans. Some of its findings, which are hard to question, have led to ongoing investigations by federal regulators and Capitol Hill.

The Journal’s latest expose finds that mail order pharmacies – again the biggest owned by the big national healthcare players — regularly overfill Medicare prescriptions. The Journal finds that excessive filling is a common practice at mail order firms. Too-frequent refills by all U.S. pharmacies cost Medicare and patients $3 billion between 2021 and 2023 says the Journal.

Mail-order pharmacies filled just 9% of Medicare prescriptions in the study period but accounted for 37% of the excess dispensing. Practices that continue overfilling include automatic 90-day refills and early refills. While federal rules require health plans to limit early refills (e.g., no earlier than 75% of the way through a prior supply or 68 days for a 90-day supply), the Journal analysis found that UnitedHealth Group’s mail-order pharmacies sent refills sooner than the 68-day threshold 11% of the time. That was almost nine times the rate of all other Medicare pharmacies.

The reason is clear: vertically integrated companies’ insurers cut great deals with their sister companies and the vertical behemoths then find many pathways to derive as much revenue as possible in the unregulated entities. The Journal has found yet another use case of this fact.

#medicareadvantage #partd #fwa #healthplans

https://www.msn.com/en-us/health/other/pharmacies-flood-medicare-patients-with-3-billion-of-extra-drugs/ar-AA1T6d3S

Johnson Under Fire From Moderates On Healthcare

As Congress returns this week, House Speaker Mike Johnson, R-LA, is facing a backlash from moderates in his already divisive caucus with a razor-thin majority. Moderates are upset that Johnson refused to hold a vote on Exchange subsidy extensions. After that, four members sided with Democrats on a discharge petition to force a vote in January. These moderates are committed to reaching a compromise with the Senate to extend the subsidies in some form.

#exchanges #healthcare #coverage #congress #gop #speakerjohnson

https://thehill.com/homenews/house/5667397-mike-johnson-house-republican-moderates/?tbref=hp

Congress Comes Back To Exchange Saga

Congress is slated to reopen next week and will return to the Exchange subsidy controversy. Some lawmakers say that arriving at a potential compromise on extending enhanced subsidies is about 50-50 right now. A vote will be held in the House on a Democratic bill to extend the subsidies with no changes for three years. At least four Republicans are expected to support the measure, which would mean the bill likely passes. The same extension was voted down in the Senate (it did not reach 60 votes), but the bill could be used for a compromise measure, which then would go back to the House. GOP leaders in each house, though, are expected to put roadblocks up to final passage.

With the reduction in subsidies and major increases in premiums, between 2.2 million and 7.3 million people may decide against renewing their insurance because of the price hikes. In 2025, over 24 million had Exchange coverage. Young people, blacks, Hispanics, and those between 250% and 400% of federal poverty are expected to see the biggest increases in their uninsured ranks.

But so far published data have not shown a massive reduction in enrollees. State officials though are seeing terminations and enrollees choosing less-generous benefits.

Because it fully made up for federal subsidy losses, New Mexico’s health insurance marketplace has reached record enrollment. More than 80,400 people have enrolled for medical or dental coverage through BeWell, the state’s ACA marketplace, as of Dec. 30. That is more than the 79,000 people that enrolled for 2025 coverage. Other states have partially replaced expiring subsidies.

Health insurance marketplace Access Health CT has extended open enrollment to Jan. 31 (by two weeks) for coverage that starts in February.

Additional articles: https://www.beckerspayer.com/payer/aca/connecticut-health-insurance-marketplace-extends-open-enrollment/ and https://www.beckerspayer.com/payer/aca/new-mexico-sees-record-aca-enrollment-after-state-replaces-expired-subsidies/

#exchanges #healthcare #coverage

https://thehill.com/policy/healthcare/5668719-aca-obamacare-subsidies-expire

Drug Prices To Climb

3 Axis Advisors reports that the costs of at least 350 drugs in the U.S. are expected to rise in 2026. And as it notes, some of the firms boosting prices are the same that just agreed to reduce prices with President Trump.

The firm also finds that a higher number of drugs will see price increases next year compared with last year, when more than 250 drugs were increased. The median price hike is about 4%.

#drugpricing #branddrugmakers

https://thehill.com/policy/healthcare/5668053-us-drug-prices-rise-2026

States Seek To Mitigate Impact Of Expiring Subsidy Enhancements

A handful of states have taken action to mitigate the impact of expiring subsidy enhancements in the Exchanges. The states include New Mexico, California, Maryland, Colorado, Connecticut, Arkansas, Texas, and Wyoming.

Most states passed appropriations to replace some of the federal subsidy losses, while others passed premium realignment laws.

#exchanges #coverage #healthcare

https://www.beckerspayer.com/payer/aca/how-states-are-responding-to-expiring-aca-subsidies/

Major Drug Policy Developments

Major drug policy developments this week.

First, the hospital lobby scored a major victory when a court ordered the new 340B rebate pilot paused. The Trump administration is seeking to experiment with rebates as opposed to upfront discounts to curb the growth in the discount drug program. The administration rightfully alleges that the program is unaccountable and does not meet the original safety net purpose.

The judge ordered a preliminary injunction against the “hastily assembled” pilot set to kick off on Jan. 1 on the basis it “likely” violates the Administrative Procedure Act’s (APA’s) arbitrary and capricious standard. 

The judge noted Congress did authorize the federal government to create a rebate model, but regulators had not followed the APA’s requirements in doing so.

Second, Rep. Anna Paulina Luna, R-FL, says she is hopeful Congress will codify President Trump’s executive order on capping prescription drug prices next year. As you know, I believe that is essential.

Third, The Wall Street Journal finds that mail-order pharmacies owned by UnitedHealth and Humana dispensed Medicare prescription refills earlier and more frequently than industry peers. The analysis found mail-order pharmacies filled 9% of Medicare prescriptions between 2021 and 2023 but accounted for 37% of excess dispensing. Too-frequent refills across all pharmacies cost Medicare and patients $3 billion during that period, the newspaper reported.

Fourth, in 2025 the Food and Drug Administration approved 73 first-time generic drugs, many impacting major disease states. This is a boon for consumers but will hit brand drug makers’ margins.

Additional articles: https://www.fiercehealthcare.com/providers/hospital-groups-file-lawsuit-enjoin-pharma-supported-340b-rebate-pilot and https://www.beckershospitalreview.com/pharmacy/73-drugs-lost-exclusivity-in-2025/ and https://www.beckerspayer.com/payer/unitedhealth-humana-mail-order-pharmacies-led-in-excessive-medicare-refills-report/ and https://thehill.com/homenews/house/5665539-luna-hopes-congress-action/

(Some articles may require a subscription.)

#340B #drugpricing #generics

https://www.modernhealthcare.com/politics-regulation/mh-340b-drug-rebates-pilot-program-judge-preliminary-injunction

Exchange Subsidy Deal 50-50

Some lawmakers are saying that there may be a 50-50 shot at obtaining an agreement to extend enhanced Exchange premium subsidies in January. But there are major obstacles. GOP leaders in each house are tending to gravitate toward the larger conservative side of their caucuses, which is dead set against an extension. Minority Leader Chuck Schumer, D-NY, wants either a clean extension or to hang the issue around the GOP’s neck in midterms.

Sen. Bill Cassidy is advocating the possibility of extending subsidies as well as seeding health savings accounts (HSAs) for some and giving Americans the ability to decide one way or another. Another leading compromise would extend for two years with some reining in of the generosity of the enhancements.

The bill could come to life in this way. Four GOP lawmakers in the House signed on to a Democratic discharge petition which will force a vote for a three-year extension in the House. That has failed to pass the Senate, but the bill could be used as a vehicle for a compromise crafted in the Senate. The bill would then go back to the House.

Meanwhile, there are no public signs, yet enrollment is falling demonstrably due to the expiration of subsidies. Federal data released on Dec. 5 showed sign-ups across all 50 states increased 7.5% (5.7M vs. 5.3M) compared with the same period in 2024. Centers for Medicare and Medicaid Services (CMS) Administrator Dr. Mehmet Oz posted on social media Tuesday that more than 15.6 million people enrolled in a plan on the federal exchanges, down from 16 million last year — just a 2.5 percent decline.

But states are appearing to see falloffs, terminations, and changes to less robust plans. Time will tell.

In other news, a good article on changes to federal regulations since Trump 47 came in. Major streamlining, eligibility restrictions, 340B reform, site neutral reform, and major cost-savings pilots.

Additional articles: https://thehill.com/homenews/senate/5662800-gop-senator-health-care-deal/ and https://www.modernhealthcare.com/politics-regulation/mh-federal-health-regulation-2025-hhs-cms/

(Some articles may require a subscription.)

#exchanges #healthcare #coverage #regulations

https://www.politico.com/news/2025/12/24/obamacare-sign-ups-are-steady-but-warning-signs-emerge-00705604

Trump Administration Unveils GLP-1 Pilot

True to an earlier announcement, the Trump administration has taken the first step toward more expansive coverage of GLP-1 weight-loss drugs in Medicare and Medicaid. The president announced major deals with GLP-1 drug makers Eli Lilly and Novo Nordisk that both reduce net costs as well as set a proposed maximum $50 copay in Medicare for all coverage of GLP-1s.

The new step includes the creation of the Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (BALANCE) Model. Under the model, the Centers for Medicare and Medicaid Services (CMS) negotiates directly with pharmaceutical manufacturers for lower net prices and standardized coverage terms. Negotiation areas include: 

• Guaranteed net pricing and potential out-of-pocket limits for beneficiaries.
• Standardized coverage criteria.
• Evidence-based lifestyle support offerings.

Participation will be voluntary for manufacturers, states, and plans. More information will be released in early 2026. The BALANCE Model will launch in Medicaid as early as May 2026 and in Medicare Part D in January 2027. Manufacturers, states, and Part D plans need to apply by January 8, 2026.

In Medicare, the model may adjust capitated payment rates for obesity and increase the government reinsurance for drug fills. Final details will be announced ahead of the 2027 Part D bid process. It is anticipated that existing users of GLP-1s in Medicaid and Medicare for approved disease states will benefit, not just new users for obesity alone. Lower costs for drugs will be via a prescribed rebate from manufacturers to Part D plans.

To bridge to 2027 in Part D, there will be a new GLP-1 payment demonstration beginning in July 2026. This will operate outside of Part D and plans will not carry risk for eligible GLP-1 products furnished under the demonstration.

In other news, the Food and Drug Administration (FDA) has approved Novo Nordisk’s oral version of the Wegovy weight loss pill. The pill forms of the drugs appear to be somewhat less potent, but are more convenient and could broaden use. Trump also gained concessions on oral forms of GLP-1s. Eli Lilly will likely gain approval of its oral GLP-1 in the coming weeks.

Additional articles: https://www.cms.gov/newsroom/press-releases/cms-launches-voluntary-model-expand-access-life-changing-medicines-promote-healthier-living and https://thehill.com/policy/healthcare/5660548-fda-approves-wegovy-weight-loss/ and https://www.healthcaredive.com/news/novo-nordisk-oral-wegovy-fda-approve-glp-1/808626/

#glp1s #weightlossdrugs #branddrugmakers #drugpricing #medicare #partd #medicaid

https://www.beckerspayer.com/pharmacy/cms-kicks-off-glp-1-model-6-notes/

Strategy On Exchange Subsidies Continues; Another Shutdown Possible

House Minority Leader Hakeem Jeffires, D-NY, predicted that an extension of enhanced Exchange subsidies will pass the House with backing from both sides of the aisle. “House Democrats are going to continue to fight to get this extension through the Congress on our side. It will pass with a bipartisan majority,” Jeffries told ABC News’ “This Week.” With four GOP members joining Democrats to force a vote on the floor in January via discharge petition, the likelihood is there that the vote could pass.

The three-year extension failed in the Senate, unable to get 60 votes. A bipartisan group there still thinks a compromise including a shorter extension, minimum premiums, an income cap, and fraud protections could be hammered out for each chamber. But there are reported barriers to a deal, including political pressures in the GOP caucus not to vote on any extension bill.

A further complication: Senate Democrats are raising the threat of another government shutdown in late January. Senate Democrats walked away from a potential deal to fund numerous departments covering about two-thirds of the discretionary budget.

Additional articles: https://thehill.com/policy/healthcare/5659243-jeffries-predicts-aca-extension/ and https://thehill.com/homenews/senate/5657868-senate-health-care-battle-obamacare/

#exchanges #healthcare #coverage #governmentshutdown

https://thehill.com/homenews/senate/5657834-senate-democrats-threaten-government-shutdown

Trump Moves Ball On Drug Prices

President Donald Trump registered more wins on drug price reform. The White House announced that nine additional pharmaceutical companies have agreed to follow a most-favored-nation (MFN) drug pricing policy, with some of the companies throwing in several months’ worth of emergency drug supplies.

As with other drug firms, the drug companies will lower the Medicaid prices for drugs that are more expensive than they’re sold in other countries, although prices are already deeply discounted through federal and state rebate programs. The firms will also deeply discount cash-pay customers’ drugs via the TrumpRx website. The deals also guarantee MFN prices on all new innovative medicines the nine companies bring to market.

Trump has now reached deals with 14 of the 17 drug makers to which he sent letters in July demanding that they lower prices.

At the same time, the Centers for Medicare and Medicaid Services (CMS) seeks to reduce Medicare drug costs through a pair of payment demonstrations announced Friday. CMS would tie the prices Medicare Part B and Part D pay for medicines to costs in foreign countries. The Global Benchmark for Efficient Drug Pricing Model, or GLOBE, would cover Part B drugs. A second mandatory initiative called Guarding U.S. Medicare Against Rising Drug Costs Model, or GUARD, would cover Part D drugs. The agency estimates that the Part B model will save $11.9 billion in net spending over seven years. Roughly a quarter of Medicare beneficiaries will participate in the program.

The models would run from 2027 through 2031, with rebate invoicing and reconciliation continuing into 2033.

Additional articles: https://thehill.com/policy/healthcare/5657095-trump-policy-pharma-agreement/ and https://www.beckerspayer.com/payer/cms-proposes-2-medicare-drug-pricing-models/

(Some articles may require a subscription.)

#drugpricing #branddrugmakers #trump

https://www.modernhealthcare.com/politics-regulation/mh-cms-globe-guard-medicare-drug-pricing