Milliman’s Post

How does a specialty medication get insurance approval? It's not solely based on a doctor's recommendation.   📋 Drug Review Process   Insurance companies use drug reviews to evaluate whether a medication would be eligible for coverage and reimbursement. A committee of members normally assesses new and existing medications. This process is necessary to manage costs while ensuring that plan members have access to treatments.   🔍 Here's what goes into evaluating a drug:   📌Clinical Evidence Review: How effective were the clinical trials in assessing the medication's use? 📌Safety: Is the medication’s place in therapy aligned with guidelines and practices? 📌Financial Impact: What are the economic implications of covering the drug? 📌Cost-Effectiveness: Does the benefit of the drug justify its cost?   Understanding this process helps demystify the reasons behind your insurance coverage decisions. 🏥 Stay tuned as we continue to explain the critical terms and processes that influence your healthcare options.   #PrivatePayors #HealthSolutions #SpecialtyPharmacy #Healthcare  

We hope that everyone had an enjoyable Christmas holiday. It is hard to believe how fast it came and how much faster it was over. However, as the holiday season begins to wind to a close, we again have to get back down to the reality of a very expensive and impactful health care, Rx, and medical insurance marketplace. We received an article titled “Why such ‘high markups’? Senators seek drug price probe of insurers who own PBMs”, written by Alan Goforth. The article’s basic theme is that costs overall are higher, resulting from the vertical control of all facets of covering health care, from pharmacy to medical by large insurance companies like United Healthcare, Aetna, Blue Cross, etc. The article cited a Wall Street Journal analysis that showed “significant mark-ups of generic drugs at specialty pharmacies owned by CVS Aetna who owns Caremark, Cigna who owns Express Scripts, and United Healthcare…” We continue to advocate that a very effective method to mitigate this is for groups of all sizes to be shown that they can unbundle this and work directly with local independent pharmacies. Insurance agents in general are not showing employers and independent pharmacies that they can unbundle this and that they should. We, however, are not only advocating this, but are doing it and have done this with great results. To learn more, join us at our upcoming webinar on January 17th, 2024 at 9:00 AM CST. Click here to RSVP: https://lnkd.in/gytMgsdg Article: https://lnkd.in/gD6qB9S5 #healthcare #business #medical #insurance

FAQ of the Week Q. We received a Request for Information from the Third Party Administrator for our self-funded medical plan regarding Pharmacy and Healthcare Cost Reporting, do we need to respond? A. Yes, please do! Ideally insurance carriers, Third Party Administrators (TPA), and Pharmacy Benefit Manager (PBMs) will manage Pharmacy and Healthcare Cost Reporting for their clients but this requires timely responses to any requests for information from these partners. As a reminder, the Consolidated Appropriations Act, 2021 (CAA) requires all group health plans to annually submit information about prescription drugs and health care spending to CMS by June 1. The CMS Reporting Instructions are the best resource for question on this reporting requirement. The Pharmacy Reporting Playbook prepared by the Alliant Pharmacy and Compliance teams can also help employers comply with their reporting obligations not otherwise being met by their carriers, TPAs or PBMs.

What exactly are P2 files for RxDC reporting? The P2 file reflects relatively straightforward information about the employer and the health plan they have offered. Examples of the P2 information employers will need to provide include who their TPA, PBM, and issuer were, what kind of insurance they offered, what their 5500 and group health plan numbers were, what state(s) their plan operated in, etc. This file acts as a “cover letter” and must be submitted any time another RxDC file is submitted. This means that if an employer’s D2-D8 files are submitted in different parts by numerous vendors, the employer’s P2 file must be included with each distinct submission. #compliance #pharma #pharmaceutical #insurance #insuranceindustry #employers #rx #rxdc

#Pharmacy_Benefit_Management Market Share to Record Steady Growth 2023-2032 https://lnkd.in/dxZ3SZEu #Pharmacy benefit #management (PBM) is a #service or industry that plays a #critical role in the management of #prescription drug benefits for #health insurance plans, self-insured #employers, and government programs. These are third-party #entities that act as #intermediaries between insurers, #pharmaceutical manufacturers, #pharmacies, and patients. CVS Health Cigna Healthcare UnitedHealth Group Anthem, Inc. Centene Corporation Abarca Health MedImpact Healthcare Systems, Inc. #technologies #marketgrowth #innovationmanagement #healthcareindustry #pharmaceuticalproducts #pharmacies #benefitmanagement

This study is a must read for those interested in Rx pricing. "Commercial insurance beneficiaries paid the entire PBM-set price 59% [!!!] of the time (5.9 million of 10 million claims), while Part D beneficiaries were impacted to a lesser degree at 25% (4.3 million of 17 million claims). ... At first glance, Figure 36 may help explain the growth of GoodRx, SingleCare, and other cashbased pharmacy programs (such as Freedom Pharmacy and the Mark Cuban Mark Cuban Cost Plus Drug Company, PBC over the last several years. (52) If the majority of patients have prescription drug benefits through their employer, and the majority of those individuals (based on Figure 36) are paying full drug prices without financial support from their health insurer and PBM, and many drug prices can be exceedingly high through insurance relative to the underlying drug’s costs, then we can better understand why there is a growing demand for solutions targeted at lowering costs at the pharmacy counter for patients." h/t to Health Tech Nerds for including the study in the weekly newsletter. So much good data here. PS - this chart is why GoodRx's recent integration w/ ESI & Caremark led by Cynthia Meiners is so innovative

Group health plan costs are increasing due to medical inflation, provider contract renegotiations, and prescription drug costs.   Is it time to review your group health plan? Would a different carrier, plan design, or addition of an HRA or medical expense reimbursement plan (MERP) help keep costs down? Have you looked at Level-Funding as an alternative to a fully insured plan? #medicalinflation #employeebenefits #grouphealthinsurance

💊 Discovering NFO in Pharmacy Billing: A Guide to Understanding New Formulary Options In the intricate world of healthcare and pharmacy management, 'NFO' holds a significant role. It stands for 'New Formulary Option,' a pivotal term in the realm of prescription drugs coverage. Imagine a formulary as a curated list of medications approved for coverage by a specific health plan. Now, when a new formulary option (NFO) emerges, it signifies the introduction of a newly approved medication into this list. For healthcare providers and pharmacists, NFOs are game-changers. They denote medications that can now be prescribed with confidence, knowing they align perfectly with a patient's insurance coverage. This alignment not only enhances patient care by ensuring access to clinically effective treatments but also alleviates financial burdens by reducing out-of-pocket expenses. Behind every NFO lies a rigorous evaluation process. These medications are scrutinized for their clinical effectiveness, safety profile, and cost considerations before earning their place on the formulary. This careful vetting ensures that patients receive medications that are not only medically suitable but also economically viable within the framework of their insurance coverage. Understanding NFOs empowers healthcare professionals to make informed decisions, providing optimal care while navigating the complexities of insurance coverage. It's a synergy where healthcare meets affordability, ensuring every prescription is a step towards better health and financial well-being. #Healthcare #PharmacyManagement #InsuranceCoverage #PatientCare

Do clinicians have the right to falsify medical records to help their patients wrestling with weight issues obtain GLP-1 products? The pressure to obtain these products is intense. The shortage of these drugs created by this demand is real for those patients that have diabetes and cardiovascular risk. Affordability challenges for companies struggling to provide health insurance for their employees and families is being strained by these and other amazing, but very expensive pharmaceutical solutions. Regarding my question above, the answer is no. Whatever the rationale, such practices are unethical and risk medical board actions and the risk of termination from both private and government program networks. For years, physician-led conservative management of weight, followed by pharmaceutical and/or surgical options has been promoted as best-practice. Despite this--some weight loss clinics, virtual services and practices have capitulated to patient demand for fast results, and, are placing their practices and patients at-risk. Time will tell where these products will take us. It might be prudent to consider that we have experienced quick fix solutions in this area of practice before that did not end well.

By unearthing the hidden intricacies of prescription drug expenses and unshackling them from bundled traditional insurance packages, companies can exercise greater control over costs.  #prescriptiondrugcosts #employeebenefits #unbundling