Medicare Part D

A Humana Inc. executive speaking at the Wells Fargo Healthcare Conference on Sept. 4 said the Medicare Advantage-focused insurer will exit 13 counties where membership was “insignificant” and reduce its plan offerings in other counties, impacting an estimated 560,000 MA members next year. The selected counties will leave Humana’s footprint largely intact, while impacted members in other counties will have Humana plans to choose from, Chief Financial Officer Susan Diamond told Wells Fargo analyst Stephen Baxter. “The exit itself is positive in the sense that those plans were not contributing,” said Diamond. And in the other counties, if Humana can “ultimately retain more of those members, that’s incrementally positive because the plan choices left behind are priced in such a way that they will be positively contributing.” Despite seeing elevated utilization and medical cost pressure in the first half of the year, the insurer on Sept. 3 reaffirmed its full-year guidance of approximately $16.00 adjusted earnings per share. Diamond during the conference added that Humana is seeing more prior authorization decision appeals than it has seen historically. She also disclosed that Humana anticipates greater utilization of supplemental benefits such as over-the-counter cards and dental services in the fourth quarter, "just recognizing the benefit changes we've made for 2025."

Centene Corp. late last month riled agents and brokers with the news that it would no longer pay new and renewal commissions for enrollments in its stand-alone Prescription Drug Plan (PDP) products. During a Sept. 4 presentation at the Wells Fargo Healthcare Conference, Centene executives for the first time publicly acknowledged the firm’s controversial decision.

“One important thing to note on PDP, partly because of the IRA [Inflation Reduction Act] changes and then final rate notice provisions at the time that we filed bids, we made the difficult decision to eliminate broker commissions this year for PDP only,” Centene CEO Sarah London emphasized during the conference. She added that “we'll continue to pay full commissions in Medicare Advantage and obviously work very closely with the broker community to support the work they do, to support our members.”

In an email to contracted brokers on Aug. 23 that has now stirred considerable controversy, Centene Corp. said it would no longer pay new and renewal commissions for enrollments in its stand-alone Prescription Drug Plan (PDP) products.

For insurance agents who previously enrolled clients in a Centene/Wellcare product and anticipated putting time and resources into continuing to serve that client, the rug was effectively pulled out from under them. Fearing that the move could set a dangerous precedent, the broker community over the last week has rallied to voice its objections and demand answers from the leading PDP carrier.

In what whistleblower attorneys say is a novel case, Humana Inc. has agreed to pay $90 million to settle False Claims Act allegations related to the Medicare Part D contracting process. The case was brought by a former employee who alleged Humana engaged in a “reverse-engineering” scheme to submit actuarially equivalent bids to CMS for Prescription Drug Plan (PDP) business that were based on inflated assumptions about the use of preferred pharmacies by low-income subsidy (LIS) members. Humana did not admit wrongdoing and stands by the merit of its assumptions.

The suit, U.S. ex rel. Steven Scott v. Humana Inc. (3:18-CV-00061-GNS-CHL), was originally filed in January 2016 in the U.S. District Court for the Central District of California. It remained under seal until 2017, after the U.S. Dept. of Justice (DOJ) declined to intervene.

Now that CMS has revealed the prices of the first 10 drugs subject to Medicare price negotiation, all eyes are on how Part D plans will cover those drugs on their formularies in 2026, when the new prices go into effect.

To that end, a recent poll from Zitter Insights offers some clues about how payers and PBMs are thinking about this thorny question.

The flash poll was conducted after CMS revealed the results of the first round of the Medicare Drug Price Negotiation Program, which was authorized by the Inflation Reduction Act. Through that process, Medicare for the first time set a Maximum Fair Price (MFP) for 10 branded drugs selected due to their high cost and lack of generic or biosimilar competition.

Nearly 12% of generic prescription drugs could have had lower out-of-pocket costs if they were purchased through the Mark Cuban Cost Plus Drug Co. (MCCPDC) rather than through a traditional pharmacy using health insurance, according to a recent JAMA Health Forum study. Karen Van Nuys, Ph.D., a leading health policy expert who was not involved in the study, tells AIS Health the Mark Cuban company is doing a “tremendous service” by making medication prices transparent, although she suggests that it remains to be seen whether the firm and other cash pharmacies will have a major impact on the prices plans and members pay for drugs.

Mark Cuban, a billionaire, founded MCCPDC in 2022 to bring more transparency to drug pricing and improve access to medications. The company discloses the amount it pays for drugs and then adds a 15% markup, $5 pharmacy fee and $5 shipping fee.

If Medicare Part D covered GLP-1 drugs for obesity, rather than just Type 2 diabetes, it could increase annual spending by $3.1 billion to $6.1 billion, according to a recent Health Affairs study.

The introduction of GLP-1 medications for treatment of diabetes and obesity has reignited the debate over Medicare’s prohibition on covering weight loss medications. In June, the House Ways & Means Committee advanced legislation that would provide a limited pathway for adults 65 and older to get anti-obesity GLP-1s covered by Medicare. The bill has not yet passed the full House.

From 2021 to 2023, the median share of health care dollars that large employers spent on pharmacy costs rose from 21% to 27%, according to the Business Group on Health’s 2025 Employer Health Care Strategy Survey. The survey also found that 56% of responding employers identified GLP-1s — which treat Type 2 diabetes, obesity and other indications — as driving health care costs to a “great extent” or “very great extent,” making it the top-cited trend driver. The next most cited cost driver was “high-cost therapies.” And when listing their top pharmacy benefit-related concerns, employers put “appropriate use and/or long-term cost implications of GLP-1s and other newer weight management medications” at the top of their list, with 70% and 20%, respectively, saying they were very concerned or concerned about that issue.

Echoing a proposal championed by the Biden administration, Democratic presidential candidate Kamala Harris said recently that if elected, she hopes to apply a $35 out-of-pocket cap on insulin to everyone in the country — not just those on Medicare. But newly published research into state out-of-pocket insulin cost caps raises questions about how much of an impact such a policy would make.

So far, 25 states and Washington, D.C., have passed legislation capping patients’ monthly out-of-pocket costs for insulin, with upper thresholds set between $25 and $100. Those caps apply only to state-regulated health insurance plans. Meanwhile, the Inflation Reduction Act (IRA) capped Medicare enrollees’ monthly out-of-pocket costs for insulin at $35, effective in 2023.

Elevance Health, Inc. and private equity firm Clayton, Dubilier & Rice (CD&R) announced on Aug. 14 the formation of Mosaic Health, a primary care delivery platform focused on value-based arrangements with payers. The companies revealed in April their plans to merge CD&R-owned apree health and Millenium Physician Group with primary care assets owned by Elevance through its Carelon Health division. Elevance CEO Gail Boudreaux said in April that the company would own a “significant minority position” in Mosaic, while Chief Financial Officer Mark Kaye said Mosaic would have more than $4 billion in annual revenue when formed.