Cigna’s Express Scripts Is Eliminating Rebates
Spurred on by demands from the Trump administration to reform, Cigna’s Express Scripts pharmacy benefits manager (PBM) is phasing out prescription drug rebates for brand drugs. Rebates are issued by brand drug makers and usually do not go to consumers at the point of sale, causing brand drugs to have a high cost at the pharmacy. The rebates are issued by Big Pharma to gain preferred placement on drug formularies.
Cigna will eliminate rebates in many of its commercial health plans in 2027. The phaseout will expand to Express Scripts clients starting in 2028 as the default option. The PBM’s phaseout program could mean a major transformation of the PBM industry, moving billions of dollars to offset consumer costs at the expense of rebates to insurers and employers as well as some amounts retained by PBMs.
The new model will save members an average of 30% each month on brand-name medications. Patients will pay the lowest available cost — whether the PBM’s negotiated rate, the consumer’s benefit copay, the cash price, or a direct-to-consumer price.
In addition, Express Scripts will adopt a cost-plus reimbursement model for pharmacies, paying them based on their cost for medications with a dispensing fee added in.
Additional articles: https://www.fiercehealthcare.com/payers/cignas-express-scripts-set-shift-away-pbm-rebates and https://www.modernhealthcare.com/insurance/mh-cigna-drug-rebates-health-plans-2027/ and https://www.beckerspayer.com/payer/cignas-evernorth-unveils-rebate-free-pharmacy-model/
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#pbms #branddrugmakers #rebates #cigna #expressscripts
https://www.healthcaredive.com/news/evernorth-express-scripts-new-pbm-model-cost-plus/803864/
Exchange Subsidy Activity Heating Up
Republicans are days away from the upcoming Exchange enrollment period without a unified plan to address the doubling of premiums for subsidized individuals due to expiring enhancements to premium subsidies. Some blame the president for his lack of urgency in extending the subsidies and intransigence among more conservative Republicans.
In other news, both the president and Republicans seem interested in taking another try at a healthcare overhaul. Trump mentioned his desire in a private meeting with congressional leaders. In addition, Centers for Medicare and Medicaid Administrator Dr. Mehmet Oz said Trump has a plan to do so (sort of). Republicans and the White House are discussing a potential subsidy extension with conservative reforms. House Republicans say they have numerous policy proposals from over the years that could be incorporated.
A new poll found that 69 percent of voters believe that healthcare is not affordable today, with that figure remaining relatively consistent across parties.
An NPR article discusses the possibility of a rate “death spiral” if enhanced Exchange subsidies expire.
Although he doesn’t support an extension of the subsidies, Sen. Rand Paul, R-KY, says a bipartisan commission should be appointed by Trump that is tasked with addressing the expiring subsidy enhancements.
Additional articles: https://www.npr.org/sections/shots-health-news/2025/10/26/nx-s1-5577940/health-insurance-government-shutdown-aca-open-enrollment-death-spiral and https://thehill.com/policy/healthcare/5572504-healthcare-affordability-voter-poll/?tbref=hp and https://thehill.com/homenews/house/5574845-speaker-johnson-gop-health-care-plan-shutdown/?tbref=hp and https://thehill.com/policy/healthcare/5573921-rand-paul-affordable-care-act-subsidies-commission/
#aca #exchanges #medicaid #healthcare #coverage
KFF Finds Fewer Docs in Medicare Advantage Than FFS
Healthcare policy group finds that on average Medicare Advantage (MA) enrollees had plans that covered only 48% of the physicians that traditional Medicare fee-for-services (FFS) beneficiaries could access. The data studied was from 2022 and looked at 4,200 individual MA plans that covered 20.3 million MA enrollees. These included Health Maintenance Organizations and Preferred Provider Organizations.
KFF notes that this illustrates a key tradeoff for beneficiaries in choosing MA vs. FFS. MA enrollees are attracted to MA’s extra benefits and caps on out-of-pocket costs but do have less access through networks.
The narrowest network plans (20th percentile) had just 32% of FFS providers and the broadest network plans (80th percentile) had 63% of FFS providers.
Additional articles: https://www.beckerspayer.com/research-analysis/number-of-physicians-halved-for-medicare-advantage-enrollees-report/ and https://www.kff.org/medicare/medicare-advantage-provider-networks-limit-enrollees-to-about-half-of-the-physicians-in-their-area-that-are-available-to-beneficiaries-in-traditional-medicare-on-average/
#medicareadvantage #providers #medicare #access #marketing
Prompt Pay in MA Could Get Tougher
Bipartisan legislation called the Medicare Advantage (MA) Prompt Pay Act would mandate MA plans pay at least 95% of clean claims within 14 days for in-network and 30 days for out-of-network claims. The Centers for Medicare & Medicaid Services (CMS) does not require MA plans to follow the same prompt payment standards as original Medicare for in-network claims. Instead, MA plans generally have 30 days to pay 95% of clean claims from non-contracted providers and 60 calendar days to pay other claims from non-contracted providers.
#claimsdenials #healthplans #providers
Health Plan Study Says Provider Abuse No Surprises Arbitration
A new industry-sponsored study finds that 39% of provider’s surprise billing disputes were ineligible for arbitration and never should have been submitted to the federal independent dispute resolution (IDR) process. Trade groups AHIP and the Blue Cross Blue Shield Association fielded responses from 25 health plans with enrollment in the commercial market. The plans provided data on their 2024 qualified IDR claims.
What’s more, the study found the arbitration panels determined only 17% of disputes were ineligible, significantly less than the plans’ finding of 39%. The plans argue the panels of an incentive to hear the cases due to fees paid.
Another recent study found that the No Surprises arbitration process has cost $5 billion since 2022.
Additional article: https://www.beckerspayer.com/research-analysis/insurers-claim-39-of-no-surprises-disputes-ineligible-for-arbitration/
#nsa #nosurprisesact #providers #healthplans
CVS To Shutter More Primary Care Sites
CVS Health plans to close sixteen Oak Street Health sites by the end of February due to financial challenges, including higher medical costs. The company is cost-cutting to the tune of $2 billion.
(Article may require a subscription.)
#cvshealth #primarycare #retailmeetshealthcare
https://www.modernhealthcare.com/providers/mh-cvs-health-oak-street-primary-care
— Marc S. Ryan
