Starting on Jan. 1, 2025, most Blue Shield of California commercial plan enrollees will have access to a Humira (adalimumab) biosimilar with a $0 copay as part of the insurer’s Pharmacy Care Reimagined model. Blue Shield announced the initiative on Oct. 1 and said it would partner with Fresenius Kabi, which manufactures a Humira biosimilar, and Evio Pharmacy Solutions, a company that Blue Shield and other Blues plans founded in 2021. As part of the agreement, Blue Shield will purchase the Humira biosimilar for a monthly price of $525, significantly below the net price of $2,100 per month for branded Humira. Blue Shield revealed the Pharmacy Care Reimagined model in August 2023 and noted it would shift from a traditional PBM contract with CVS Health Corp.’s Caremark to a pharmacy benefits arrangement with five different vendors.

After a yearslong investigation into Clover Health Investments Corp.’s business practices, the U.S. Securities and Exchange Commission (SEC) does not intend to recommend an enforcement action related to the investigation. As Clover previously disclosed, the SEC in February 2021 launched its probe shortly after a 2021 report from Hindenburg Research criticized multiple Clover business practices and accused its leaders of failing to disclose when the firm went public that it was under an active investigation by the Dept. of Justice. The MA-focused startup earlier this year settled a series of shareholder-led class action lawsuits that related to the DOJ probe. According to Sept. 30 SEC filing by the company, the SEC on Sept. 26 informed Clover that it had concluded its investigation and, “based on the information that the SEC had as of the date of the Notice,” it would not seek an enforcement penalty.

The HHS Office of Inspector General (OIG) is asking Humana Inc. and a division of CVS Health Corp.’s Aetna to refund the federal government a combined $11 million for estimated overpayments, according to two reports posted on Sept. 25. OIG is seeking $6.8 million from Humana and $4.2 million from Aetna’s HealthAssurance based on extrapolated audit findings. For the Humana audit, the agency examined a random sample of 240 enrollee-years for which Humana submitted high-risk diagnosis codes in 2017 and 2018. It found that for 202 enrollee-years, the claims submitted by Humana to CMS “were not supported by the medical records and resulted in $497,225 in overpayments.” HHS OIG performed a similar analysis for HealthAssurance and found the medical records did not support the diagnosis codes for 222 of the 269 sampled enrollee-years and resulted in $657,744 in overpayments. Humana and Aetna both disagreed with the findings, according to the report.

Sen. Bernie Sanders (I-Vt.) said during a Senate hearing that major PBMs promised to expand access to Ozempic and Wegovy if Novo Nordisk agrees to lower the list price. In a tense hearing on Sept. 24 held by the Senate Health, Education, Labor and Pensions Committee, Sanders, the committee chair, sought answers from Novo CEO Lars Jorgenson as to why the company’s semaglutide list prices top $1,000 a month in the U.S., noting that the drugs can cost anywhere from $130 to even $59 in other countries. Ozempic and Wegovy, both GLP-1 drugs, treat Type 2 diabetes and obesity, respectively. Sanders challenged Jorgenson to lower the U.S. list price, noting that The Cigna Group’s Express Scripts, CVS Health Corp.’s Caremark and UnitedHealth Group’s Optum Rx pledged to expand coverage of the diabetes and obesity medications. Jorgenson did not commit to a price reduction, saying “I don’t know under which conditions such a promise comes,” but he seemed to remain open to the idea if it helps patients access more affordable medicine. Jorgenson also noted that the $1,000 drug list price is a starting point for payer negotiations and said the company pays 75 cents per dollar received due to discounts, fees and rebates.

Point32Health CEO Cain Hayes has departed the company to pursue other opportunities, according to a Sept. 13 press release. Eileen Auen, Point32Health’s chair of the board, took over as interim CEO until the company can find a permanent replacement for Hayes, who had led Point32 since its inception in 2021 through the merger of Harvard Pilgrim Health Care and Tufts Health Plan. Auen has worked in health care management roles for more than 25 years, including as CEO of APS Healthcare, a behavioral health company, and PMSI, a PBM.

After failing to meet minimum medical loss ratio (MLR) requirements for three years in a row, Centene Corp. is prohibited from enrolling new beneficiaries into its Medicare Advantage Prescription Drug (MA-PD) plan in Missouri, while a UnitedHealthcare (UHC) subsidiary regained enrollment abilities after a similar suspension. According to a Sept. 6 letter posted to CMS’s Parts C and D enforcement actions webpage, Centene’s Wellcare of Missouri Health Insurance Company, Inc. reported MLRs of 78.9%, 77.7% and 84.0% for contract years 2021, 2022 and 2023, respectively. When an MA organization has an MLR for a contract that is below 85.0% for three or more consecutive years, CMS must suspend the MAO’s ability to accept new enrollments in the second succeeding contract year after the third consecutive year of noncompliance, explained CMS. The enrollment freeze will take effect for any coverage beginning Jan. 1, 2025, through Dec. 31, 2025, and the contract will be removed from the Medicare Plan Finder list of available MA-PD plans during the 2025 Annual Election Period that begins on Oct. 15. According to CMS enrollment data for September, Wellcare of Missouri serves 4,254 MA enrollees, including 2,872 with Part D coverage. Meanwhile, UHC’s Care Improvement Plus South Central Insurance Co. was released from an enrollment suspension after reporting an MLR exceeding 85.0% for contract year 2023, according to a separate notice issued on Sept. 6. The UHC plan, which currently serves about 8,600 MA-PD enrollees, will be allowed to enroll beneficiaries during the upcoming AEP.

Elevance Health, Inc. has agreed to acquire Indiana University Health Plans, according to a Sept. 10 press release. IU Health Plans, a subsidiary of Indiana University Health, has 19,000 Medicare Advantage members and 12,000 fully insured commercial beneficiaries. It will become a part of Anthem Blue Cross and Blue Shield in Indiana, which is Elevance’s insurance affiliate in the state. The deal is subject to customary closing conditions and is expected to close by the end of the year.

After the chairman of a key House committee accused three top PBM executives of giving “fraudulent testimony,” one of those companies is hitting back. The heads of CVS Health Corp.’s Caremark, The Cigna Group’s Express Scripts and UnitedHealth’s Optum Rx testified before the House Committee on Oversight and Accountability on July 23 to defend their companies against skeptical lawmakers. In late August, committee Chairman James Comer (R-Ky.) sent letters to CVS’s David Joyner, Express Scripts’ Adam Kautzner and Optum Rx’s Patrick Conway, M.D., offering them an opportunity to “correct the record” regarding statements they made, such as Joyner’s assertion that Caremark pays CVS-affiliated pharmacies less than other pharmacies in its network. In a Sept. 10 letter, Caremark responded by asserting that Joyner’s testimony was “accurate and supported by comprehensive analyses of CVS Caremark’s data by an outside economist.”

Otezla (apremilast) is available in the U.S. for the treatment of pediatric patients 6 to 17 years of age and weighing at least 20kg with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy, Amgen Inc. said Aug. 20. The FDA approved the agent for that use on April 25 while also registering an additional packaging facility to support new packaging configurations for the pediatric population.

Elevance Health, Inc. will offer Affordable Care Act exchange plans in three new states next year. The insurer’s Wellpoint-branded plans will expand into Florida, Maryland and Texas — all states where it has a managed Medicaid presence. According to AIS’s Directory of Health Plans, Elevance Health has approximately 1 million members enrolled in ACA exchange plans, making it the insurer’s smallest market segment. As of 2024, the insurer offered exchange plans in 10 states, with California, Virginia and New York representing its three largest markets.

The value of Affordable Care Act marketplace plans decreased from 2014 to 2023, according to a Paragon Health Institute report published on Sept. 3. The authors — actuaries Daniel Cruz and Greg Fann — noted that just 11% of exchange customers were enrolled in plans with broad provider networks in 2023, down from 36% in 2014. During that same period, gross premiums in the individual marketplace increased 50% more than premiums for people enrolled in employer plans. The authors argued that “the ACA insurance rules caused premiums to increase and led insurers to offer narrower and more restrictive networks over time” and that “the design of the ACA premium tax credits has also incentivized enrollees to select lower-quality plans.”