Balance And Bridge Proposed For GLP-1s
The Centers for Medicare and Medicaid Services (CMS) has issued requests for applications for Medicare Part D plans and Medicaid agencies to join the BALANCE model that would bring GLP-1 weight-loss drugs to Medicaid and Medicare in 2026 and 2027, respectively, for those with obesity but not other qualifying disease states for the drugs.
CMS will negotiate prices for such drugs with brand drug makers. Participating plans and Medicaid agencies must cover all model drugs from the included manufacturers, and the existing Part D weight-loss coverage exclusion would not apply. The drugs must fall under a plan’s basic benefit structure. In Part D, at least 90% of a plan’s eligible population must be included.
Narrower risk corridors are available to plans. Enhanced alternatives and employer group waiver plans must cap beneficiary spending at $50 for a month’s supply during the initial coverage phase. For basic alternative and actuarially equivalent plans, the cap is $125 per month supply. Prior authorization would also be standardized across the model. The documents outline body mass index thresholds, provider attestation, and confirmation that patients are pursuing lifestyle modification.
CMS is also proposing a pilot in Medicare known as the Medicare GLP-1 Bridge to begin providing coverage as early as mid-2026. Wegovy and Zepbound would be provided to eligible beneficiaries enrolled in Medicare Part D for a $50 copayment. The short-term program will operate outside the Part D benefit for its duration from July 1 to December 31, 2026. Providers will submit GLP-1 prescriptions and prior authorization requests to a central processer managed by CMS.
#glp1s #weightlossdrugs #medicare #partd
Non-Network Insurance Firms Ready For Exchange Submissions
A new Trump administration proposed regulation would allow non-network plans to be qualified health plans on the Exchanges. This opens up major opportunities for some recent startups offering such benefits. Many of them rely on reference pricing to reduce costs for employers today. Others feature cash-pay benefit programs.
(Article may require a subscription.)
#exhanges #trump #regulations #coverage
https://www.modernhealthcare.com/insurance/mh-cms-aca-exchanges-rule-non-network-plans
Hims & Hers Cuts Deal With Novo
Facing a lawsuit from Novo Nordisk for its plans to create a copycat weight-loss drug, Hims & Hers has done and about-face and will now sell Novo Nordisk branded GLP-1 products. It, too, will limit its fulfillment of compounded versions. The company will later this month offer multiple dosages of Ozempic injections as well as Wegovy injectables and oral medications. Novo will dismiss its lawsuit.
Additional articles: https://www.fiercehealthcare.com/health-tech/hims-hers-makes-deal-novo-nordisk-it-shifts-obesity-strategy and https://www.medpagetoday.com/endocrinology/obesity/120218
#glp1s #weightlossdrugs #branddrugmakers
https://thehill.com/policy/healthcare/5775413-novo-nordisk-hims-hers-collaboration
— Marc S. Ryan
