Illuminations Strategy Group’s Post

🔍 Insight into Pharmacy Benefit Managers (PBMs): The Gatekeepers of Affordable Drugs A recent report by the FTC has shed light on the significant influence that Pharmacy Benefit Managers (PBMs) have over patient access to affordable medications. PBMs play a critical role in the healthcare system, negotiating drug prices on behalf of insurers, but their practices can also impact drug availability and pricing for patients. 📊 Key Findings: - Market Power: PBMs wield substantial control over which drugs are covered by insurance plans and at what cost. - Pricing Practices: The report highlights concerns about the opaque pricing strategies of PBMs, which may contribute to higher out-of-pocket costs for patients. - Access to Medications: Patients often face barriers to accessing necessary medications due to PBM practices, such as formulary restrictions and prior authorization requirements. 💡 Implications for Healthcare: The FTC's findings underscore the need for greater transparency and regulation in the PBM sector to ensure that patients can access affordable medications without unnecessary hurdles. As we continue to innovate in biotech and drug discovery, it's crucial to address these systemic issues to improve patient outcomes. 👉 Read more about the FTC report and its implications for the healthcare industry: https://lnkd.in/gNuMD6_5 #Healthcare #PharmacyBenefitManagers #AffordableDrugs #PatientAccess #BiotechNews

The three biggest pharmacy benefit managers will come before the House Committee on Oversight and Accountability to explain their role in the increasing medication prices in the U.S., according to an announcement on Tuesday by committee Chairman James Comer (R-Ky.). The hearing, set for July 23, will include Adam Kautzner, president of Evernorth Care Management and Express Scripts, David Joyner, executive vice president of CVS Health and president of CVS Caremark, and Patrick Conway, CEO of OptumRx. According to Comer’s announcement, the session will probe how these pharmacy middlemen reinforce anticompetitive practices in the industry, in turn increasing prescription drug prices and compromising patient care. #biotech #biopharma #pharma #drugpricing #PBM

💊 Prescription drug costs have long been a concern for Medicare eligible individual across the nation, often presenting significant financial burdens and barriers to accessing essential medications. However, recent discussions and proposed reforms suggest that positive changes may be on the horizon. 📈 The potential for improved pricing stems from various factors, including legislative proposals aimed at increasing transparency in drug pricing, enhancing competition among pharmaceutical companies, and empowering consumers to make more informed decisions about their healthcare options. 🤝 Collaborations between healthcare stakeholders, including policymakers, industry leaders, and advocacy groups, are fostering dialogues to address the root causes of escalating drug costs and explore innovative solutions. 🔬 From exploring alternative reimbursement models to leveraging technology to streamline healthcare delivery, these initiatives signify a collective effort to drive positive change and ensure that healthcare remains accessible and affordable for all. 💡 While challenges persist, the momentum toward meaningful reform offers a glimmer of hope for millions of individuals who rely on Medicare and prescription medications to manage their health needs. 🌐 As we look ahead, let's remain vigilant and engaged in shaping a healthcare landscape that prioritizes affordability, accessibility, and quality of care for every individual. Together, we can make a difference and pave the way for a healthier, more equitable future. #Medicare #PrescriptionDrugs #Affordability #AccessToCare #HealthEquity #PositiveChange #FutureOfMedicare

We recently completed thousands of RxDC filings for plan sponsors. Did you look at the reporting data on rebates and spread for your plan? Most don't - what a shame. Why? The FTC is suing the PBM's: https://lnkd.in/ezQBejdT The FTC plans to file lawsuits related to rebates brokered with drug manufacturers, people familiar with the matter told the WSJ. The six largest control more than 90% of the market, according to the FTC report. What they "discovered" - the last one, though.... ◾ PBMs have opaque contractual relationships ◾ PBMs yield power over independent pharmacies ◾ Vertically integrated PBMs may have the ability & incentive to prefer their own affiliated businesses ◾ Likely creates the ability & incentive to generate the greatest revenue & profits via certain drugs & affiliated pharmacies ◾ Affiliated pharmacies receive significantly higher reimbursement rates than unaffiliated pharmacies ◾ They negotiate prescription drug rebates that are expressly conditioned on limiting access to potentially lower cost generic alternatives Healthcare Reporting MZQ Consulting, LLC CXC Solutions Benefit Comply, LLC #Fiduciary #CAA

Why do you care about this? Because we all need more transparency in drug pricing for a group health plans. Summary of attached article: The Centers for Medicare & Medicaid Services (CMS) issued guidance on Oct. 2 for the next phase of the drug price negotiation program, part of the Inflation Reduction Act. The first round, which negotiated prices for 10 drugs, is expected to save $1.5 billion in out-of-pocket costs by 2026. The second round will focus on 15 drugs, with new prices taking effect in 2027. CMS aims to make the process transparent and inclusive, engaging stakeholders through technical calls and roundtables. Despite legal challenges from pharmaceutical companies, the program continues with efforts to lower drug prices for Medicare beneficiaries. #prescriptiondrugpricing #employeebenefits #hr #humanresouroces Rubicon Benefits, a division of World

The 8/19 Healthcare Labyrinth Blog is live. Click below to read. With the settting of Medicare drug prices for the first 10 drugs for 1/1/2026, one think is clear -- Big Pharma's apocalypse predictions did not occur. #healthcare #healthcarereform #healthinsurance The Healthcare Labyrinth Marc S. Ryan 🇺🇦 https://lnkd.in/eVVkXrKE

CMS System To Verify Negotiated Drug Prices Reach Patients Sparks Compliance, Operational Concerns Bloomberg Law (5/29, Phengsitthy, Subscription Publication) reports, “The Medicare system proposed by the Biden administration to verify negotiated drug prices reach eligible individuals is generating concerns about compliance and operational challenges for manufacturers and dispensing entities.” CMS “continues to swiftly roll out its drug price negotiation program after publishing a draft guidance earlier this month for the next cycle of its price-setting scheme.” Public comments on the draft guidance are “underscoring the slew of responsibilities handed to drugmakers and dispensing entities, such as pharmacies, to carry out the drug’s maximum fair price.” https://lnkd.in/gtv5hYYh

This is how CVS Caremark and GoodRx are robbing patients and pharmacies. Patient copay: $45.83 Drug cost: $23.86 CVS/GoodRx Fee: $38.50 Profit: (-$16.03) That's right, the PBM and GoodRx are charging the patient 192% of drug cost while charging the pharmacy 162% of the drug cost. The pharmacy keeps 30% of drug cost, a 70% loss and the patient pays an inflated fee. CVS Caremark is bouncing down these claims to GoodRx, without patient or pharmacy permission, and then the pharmacy is being charged outrageous fees. Pharmacies are forced to run these claims as cash to not take a huge loss, leaving the patient without money going toward their deductible. CVS Caremark wins if they get to charge the fee and Aetna wins if the patient doesn't have this count toward their deductible. The patient and the pharmacy lose. Price fixing and vertical integration at their finest. A marriage of greed despotism. And this for a schedule II medication that brings along with it more costs and risks than normal for the pharmacy. There is no incentive to even exist. Oh, and GoodRx is selling the patient's healthcare information on top of everything. Let's not forget that part. Pharmacies have an ethical obligation to try to limit these claims in the name of patient privacy. #Pharmacy #PBM

The 8/19 Healthcare Labyrinth Blog is live. Click below to read. With the settting of Medicare drug prices for the first 10 drugs for 1/1/2026, one think is clear -- Big Pharma's apocalypse predictions did not occur. #healthcare #healthcarereform #healthinsurance The Healthcare Labyrinth Marc S. Ryan 🇺🇦 https://lnkd.in/eP6Gut4H

More info on GoodRx being embedded inside regular PBM insurance processing. Joey Dizenhouse, FSA, MAAA Joey Mattingly Adam Fein Antonio Ciaccia Sophia Herbert Thanks for sharing my YouTube video, here is more related info.