What to Do When You Can’t Attest

What to Do When You Can’t Attest

Among other things, the Consolidated Appropriations Act (CAA) requires group health plans to attest that they are in compliance with the CAA’s gag clause prohibition. TPAs and PBMs seem ready to attest (or sub-attest).

But what’s an employer to do if its plan is not in compliance? And what if the TPA or PBM doesn’t contractually restrict the data, but in practice restricts the data? Is it okay for a TPA or PBM to restrict information as long as they don’t contractually do so? This sure seems contrary to the intent of the law! (more…)

Reality Check: PBMs Make Commissions for Selling Drugs

Reality Check: PBMs Make Commissions for Selling Drugs

Most PBMs would describe their mission as “managing” the cost of drugs and making them more affordable for customers (benefit plans and their members). They like to position themselves as loyal negotiators working on behalf of plans in dealing with drug manufacturers.

This role has led to two key pricing components: discounts and rebates. Both are touted by the industry as important ingredients in the effort to lower drug benefits costs. But are they really? (more…)

A Question of Transparency

A Question of Transparency

Transparency is a hot topic these days. Americans are searching for transparent drug pricing, transparent hospital pricing, transparent broker revenue, and more. Vendors are lining up to address this issue. Sometimes that’s responding to legal mandates for reporting. Sometimes it’s sales spin to meet market demand. And sometimes it’s actually a few companies that do business differently.

This is clearly an issue that most corporate health plan managers want to address. But how does a corporate buyer tell the difference between real transparency and the so-called variety? (more…)

October is Pharmacists Month

October is Pharmacists Month

October is American Pharmacists Month ꟷ a celebration of the invaluable work done by pharmacists and the vital role that they play in society. So, go hug your favorite pharmacist! [Wait a second. Check that. It may not be appropriate.]

How about we just take a moment to reflect on and appreciate the pharmacists who have played important roles in our lives. For me, that means giving a shout-out to Kelly Prymicz and Lucia Vescera ꟷ two PharmDs that I am so grateful to be able to work with each day. (more…)

What About Us?

What About Us?

The recently enacted Inflation Reduction Act includes a series of provisions intended to reduce prescription drug costs for Medicare beneficiaries. Because the bill got through Congress via the budget reconciliation process, it was not allowed to include drug pricing provisions that apply to the commercial market (i.e., employer-sponsored health plans).

So, the law couldn’t do it, but can employers do it on their own? Or maybe the bigger question is: Will they? Worse yet, will this law create a significant cost shift from Medicare to private sector plans? Only time will tell! (more…)