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Small-molecule drugs and biologics may produce similar health benefits, but because small molecules tend to be priced lower than biologics, they often represent better value, according to a recent Health Affairs study. And the study authors argued those findings suggest it could be worth revising how the Medicare Drug Price Negotiation Program is set up.

The Inflation Reduction Act of 2022 requires that Medicare negotiate a Maximum Fair Price for selected small-molecule drugs nine years after they were approved by the FDA. Whereas for selected biologics, the negotiated price takes effect after 13 years.

Copay maximizer programs are gaining popularity among payers while copay accumulators appear to be losing some of their appeal, according to the annual Copay Accumulator & Maximizer Programs Special Report published by AIS Health’s parent company, MMIT. The report was based on surveys of 35 commercial insurers and PBMs representing 121.0 million lives.

About 39% of people were enrolled in plans with copay accumulators in 2024 on average, down from 47% in 2023. And 47% of enrollees were in plans with copay maximizer programs. On average, payers anticipated that about 48% and 57% of plan members will be covered by plans with copay accumulators and maximizers within the next 12 months, respectively.

Premiums for many stand-alone Medicare Part D Prescription Drug Plans will go up moderately in 2025, while the number of PDP options for beneficiaries will drop significantly, according to AIS Health’s analysis of the recently released CMS Medicare Advantage and Part D landscape files.

The Inflation Reduction Act, passed in 2022, ushered in a host of policy changes to the Part D benefit that will take effect in 2025: Most notably, Medicare Part D beneficiaries’ out-of-pocket drug costs will be capped at $2,000 annually and Part D plan sponsors will be responsible for 60% (up from 20%) of any costs their enrollees incur beyond that cap. As a result, the Medicare Part D national average monthly bid amount (NAMBA) is projected to increase by $115, nearly 180%, to $179.45 in 2025.

Enhanced Affordable Care Act subsidies reduce out-of-pocket premiums mostly for adults ages 50 and older and for those living in states where monthly premiums for ACA marketplace plans are high, according to a recent Urban Institute study.

Enhanced advance premium tax credits (APTCs) were initially implemented as part of the 2021 American Rescue Plan Act and extended through 2025 by the Inflation Reduction Act. They offer more generous subsidies than were available under the original ACA rules for people with incomes at or below 400% of the federal poverty level (FPL), which for 2024 are $60,240 for an individual and $81,761 for a couple. Additionally, the enhanced APTCs limit premium contributions to 8.5% of income for marketplace enrollees with incomes above 400% of FPL.

Overall satisfaction with PBMs is at a decade-long low this year, according to the 2024 Pharmacy Benefit Manager Customer Satisfaction Report, published by Pharmaceutical Strategies Group, an EPIC company. The report also showed that payers were seeking improvements in the PBM industry and were willing to be part of the disruptive change.

The report is based on responses from 248 benefits leaders at employers, unions/Taft-Hartley plans, health plans, and health systems, and it was conducted from May 10, 2024, through June 7, 2024.

Medicare Advantage plans are set to receive at least $11.8 billion in quality bonus payments in 2024, according to a recent analysis by the Kaiser Family Foundation (KFF). This figure represents an 8% decline from the $12.8 billion awarded in 2023, a reduction that was not surprising given the expiration of pandemic-era policies that temporarily boosted Star Ratings for some plans. But with rising cut points and looming program changes such as the Health Equity Index (HEI) replacing the current reward factor, payers may struggle to improve their Star Ratings — and thus boost bonus payments — moving forward.

More than 25 million people lost their Medicaid or Children’s Health Insurance Program (CHIP) coverage and over 56 million had their coverage renewed during the Medicaid eligibility redetermination process, according to a KFF analysis of data released by states and CMS. Though millions have been disenrolled, nearly 10 million more people are currently enrolled in Medicaid/CHIP than at the start of the pandemic.

Starting in April 2023, states were permitted to resume disenrolling people from Medicaid who no longer qualify after a multiyear pause of routine eligibility checks during the COVID-19 public health emergency. Compared to pre-pandemic levels, total Medicaid/CHIP enrollment is now higher in all but four states: Colorado, Montana, Arkansas and Tennessee. Missouri and North Carolina saw Medicaid/CHIP enrollment growth of more than 50%, as of May 2024.

Overall satisfaction with PBMs is at a decade-long low this year, according to the 2024 Pharmacy Benefit Manager Customer Satisfaction Report, published by Pharmaceutical Strategies Group, an EPIC company. The report also showed that payers were seeking improvements in the PBM industry and were willing to be part of the disruptive change.

The report is based on responses from 248 benefits leaders at employers, unions/Taft-Hartley plans, health plans, and health systems, and it was conducted from May 10, 2024, through June 7, 2024.

Lobbying spending by the health care industry has increased steadily over the past decade, reaching $129.3 million in 2023, according to data compiled by OpenSecrets. Among the major health plans and industry organizations, Blue Cross Blue Shield plans, AHIP, The Cigna Group and UnitedHealth Group spent the most during the 2023-2024 period, with BCBS plans spending more than $43 million from 2023 through the second quarter of 2024.

Since 2016, the health services/HMOs industry, which traditionally gives more to Republicans, has shifted to distribute more campaign funds to Democratic lawmakers. With the 2024 presidential election around the corner, around 57.3% of funds were donated to Democrats in the 2023-2024 election cycle. Among the top 20 lawmakers who received the most contributions from the industry during this election cycle, 11 are Democrats. Kamala Harris, who is running for president after President Joe Biden dropped out and endorsed her, topped the list and received over $2,347,000. Former President Donald Trump, the Republican presidential nominee, received $638,421.

In recent years, commercial health plans have increasingly opted to place both biosimilars and their reference biologics on preferred tiers in their formularies, according to a recent Health Affairs study.

The researchers analyzed coverage and market share for seven biologics — also known as “originator products” — and 20 corresponding biosimilars from the Tufts Medical Center Specialty Drug Evidence and Coverage Database and the IQVIA Longitudinal Access and Adjudicated Data Set from August 2017 to August 2022. The study categorized the payers’ coverage policies as: