More Insurance Company Denials
One Michigan insurance company made the decision to deny a life-saving CAR-T treatment because gene therapies aren’t drugs, despite a state law requiring coverage for cancer therapies. A ProPublica story looks at one case in which an insurer denied covering Kymriah. The patient died at the age of 50 from an aggressive form of lymphoma.
History of the PBM Industry
A recent article in JAMA Health Forum provides an overview of how the role of pharmacy benefit manager has evolved. In this paper, Ge Bai, Ph.D., of the Johns Hopkins Carey Business School, David A. Hyman, M.D., of Georgetown University and T. Joseph Mattingly II, Pharm.D., indicate that PBMs may adapt their business models to minimize the impact of any legislative or regulatory approaches of reform.
Class Action Suit is Filed Against United Healthcare
A California-based law firm has a class-action suit against United Health Group, alleging that United Healthcare Medicare Advantage illegally used an algorithm to deny rehabilitation for people with Medicare, according to a StatNews article. Previously, StatNews had reported about the use of the algorithm.
Payers Recognize the Benefits, but Still See Weight Loss Drugs through a Cost Lens
April 12th 2024Jeffrey Casberg, M.S., R.Ph., a senior vice president of clinical pharmacy at IPD Analytics LLC, a drug intelligence firm that advises payers and pharmaceutical companies, talks about how payers are thinking about weight-loss drugs.
Humira Biosimilars Have a Slow Uptake, Finds Samsung Bioepis Report
April 8th 2024Caps on Medicare Part D cost sharing as a result of the Inflation Reduction Act, could reduce members’ financial incentive for switching to a biosimilar, suggests the newest Samsung Bioepis Quarterly Biosimilar Market Report.