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Leslie Small

Recent Posts

Trends That Matter for Copay Accumulator Programs

Posted by Leslie Small on Apr 22, 2021

Thanks to recent regulatory moves and the increasing prevalence of copay accumulator/maximizer programs, the tactics that payers use to counter drug manufacturer copay assistance continue to be a controversial topic in the health care sector, AIS Health reported.

Copay accumulators work by preventing any monetary assistance that pharmaceutical companies offer commercially insured patients from counting toward their deductible or out-of-pocket maximum. Their close cousin, copay maximizers, take the total amount of a manufacturer's copay offset program and divide it by 12, and that amount becomes the new monthly copayment for all patients on any given drug over the course of a year.
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Topics: Industry Trends, Data & Analytics, Payer

Radar On Market Access: UnitedHealth Reports 'Good Start to the Year,' But Expects COVID Earnings Hit Later

Posted by Leslie Small on Apr 22, 2021

UnitedHealth Group began the first quarter of 2021 on a high note, reporting earnings per share (EPS) and a medical loss ratio (MLR) that both beat the Wall Street consensus estimate and saying it expects to achieve greater full-year earnings than it previously estimated, AIS Health reported. However, executives warned that the majority of the unfavorable COVID-19-related impact they're expecting will transpire in the second half of the year.

UnitedHealth expects roughly 70% of the predicted COVID-related $1.80 EPS hit to occur in the back half of the year, Chief Financial Officer John Rex said during an April 15 conference call to discuss the company’s financial results. He said that projection is based on UnitedHealth's prediction that as the year wears on and vaccination rates rise, people will increasingly be able to access higher-acuity, previously deferred care.

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Topics: Industry Trends, Data & Analytics, Payer

Perspectives on ACA Subsidy Expansion

Posted by Leslie Small on Apr 15, 2021

For an individual health insurance market that is already hitting its stride, the new pandemic relief legislation's expansion of Affordable Care Act (ACA) subsidies is yet another positive catalyst that should make the exchanges more attractive to insurers and customers alike, experts tell AIS Health.

Under the American Rescue Plan, which President Joe Biden signed into law on March 11, individuals who already qualified for premium tax credits under the ACA will see more generous financial aid. In addition, people who earn more than 400% of the federal poverty level (FPL) will be eligible for reduced premiums for the first time thanks to a provision that caps marketplace premiums at 8.5% of all enrollees' income.
 
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Topics: Industry Trends, Data & Analytics, Payer

Radar On Market Access: Evernorth Drug Trend Report Highlights Pandemic's Impact on Utilization

Posted by Leslie Small on Apr 13, 2021

In the 2020 Drug Trend Report recently released by Evernorth, the Cigna Corp. division added yet another chapter to the growing volume of data detailing the profound effects that the COVID-19 pandemic has had on health care, AIS health reported.

On the one hand, the massive amount of deferred routine and elective health care utilization had a dampening effect on the number of new medication users that Evernorth — which houses the PBM Express Scripts — recorded in 2020. New users of asthma/COPD medications dropped the most, by 7.1% year over year, likely reflecting the avoidance of clinical settings among a group that is at particular risk of contracting severe COVID-19.

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Topics: Industry Trends, Data & Analytics

Radar On Market Access: New Administration's Stance on Copay Accumulators Remains Unclear

Posted by Leslie Small on Mar 30, 2021

Thanks to recent regulatory moves and the increasing prevalence of copay accumulator/maximizer programs, the tactics that payers use to counter drug manufacturer copay assistance continue to be a controversial topic in the health care sector, AIS Health reported.

Copay accumulators work by preventing any monetary assistance that pharmaceutical companies offer commercially insured patients from counting toward their deductible or out-of-pocket maximum. Their close cousin, copay maximizers, take the total amount of a manufacturer's copay offset program and divide it by 12, and that amount becomes the new monthly copayment for all patients on any given drug over the course of a year.

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Topics: Industry Trends, Market Access, Payer

Radar On Market Access: Health Insurers May See Earnings Hit From COVID Vaccine Reimbursement Hike

Posted by Leslie Small on Mar 25, 2021

CMS has significantly boosted the amount that Medicare will pay for administering COVID-19 vaccines, a move that appears to be a positive development for health care providers and retail pharmacies but a potential headwind for commercial health insurers, AIS Health reported.

Previously, the national average Medicare payment rate for administering single-dose vaccines was $28, but CMS on March 15 increased that to $40. For two-dose vaccines, the rate rose from $45 to $80.

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Topics: Industry Trends, Data & Analytics, Payer

Radar On Market Access: How Will Subsidy Expansion Impact ACA Marketplaces?

Posted by Leslie Small on Mar 23, 2021

For an individual health insurance market that is already hitting its stride, the new pandemic relief legislation's expansion of Affordable Care Act (ACA) subsidies is yet another positive catalyst that should make the exchanges more attractive to insurers and customers alike, experts tell AIS Health.

Under the American Rescue Plan, which President Joe Biden signed into law on March 11, individuals who already qualified for premium tax credits under the ACA will see more generous financial aid. In addition, people who earn more than 400% of the federal poverty level (FPL) will be eligible for reduced premiums for the first time thanks to a provision that caps marketplace premiums at 8.5% of all enrollees' income.

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Topics: Industry Trends, Data & Analytics, Payer

Perspectives on Stock Selloff Following CVS 4Q Earnings Report

Posted by Leslie Small on Mar 18, 2021

Although CVS Health Corp.'s stock price dropped about 5% after the company reported its fourth-quarter and full-year 2020 financial results on Feb. 16, equities analysts seemed to be unshaken in their view that the firm — which owns health insurer Aetna — has strong fundamentals, AIS Health reported.

For the fourth quarter of 2020, CVS's net income of $975 million was down 44% compared with the prior-year period, a result the company partially attributed to lower operating income driven by the impact of the COVID-19 pandemic on its Health Care Benefits and Retail/Long-Term Care segments. For the full year 2020, CVS's operating income and net income increased relative to 2019.
 
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Topics: Data & Analytics, Payer

Radar On Market Access: Ohio Names New Medicaid PBM, Sues One of Current Vendors

Posted by Leslie Small on Mar 16, 2021

Ohio recently cleared a key hurdle in its plan to revamp how Medicaid enrollees' pharmacy benefits are managed, choosing Gainwell Technologies as the single PBM that will replace big-name firms including Cigna Corp.'s Express Scripts, CVS Heath Corp.'s Caremark, UnitedHealth Group's OptumRx and Centene Corp.'s Envolve Pharmacy Solutions, AIS Health reported.

Although PBMs and insurers generally oppose state moves to carve out pharmacy benefits from their Medicaid managed care contracts, Ohio says it expects the new single-PBM approach will "drive transparency, reduce pharmacy costs and simplify provider administration."

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Topics: Industry Trends, Market Access, Payer

Trends That Matter for Rx Benefits in Medicaid

Posted by Leslie Small on Feb 25, 2021

Beginning in April, California and New York will join a growing list of states that have opted to carve out prescription drug benefits from their Medicaid contracts with insurers, wagering that the state can do a better job at negotiating drug prices with manufacturers than managed care organizations and their contracted PBMs, AIS Health reported.

"I think the pharmacy benefit overall will be something that states are looking at in order to find savings in some way — whether through carveouts or through another policy — just because there are limited levers that the state is going to be able to pull to save money," says Rachel Dolan, a senior policy analyst with the Kaiser Family Foundation’s Program on Medicaid and the Uninsured.
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Topics: Industry Trends, Market Access, Data & Analytics, Payer