In a notable departure from the commercial marketplace, the most common pharmacy benefit structure among Prescription Drug Plans (PDPs) and Medicare Advantage-Prescription Drug plans (MA-PDs) under Medicare Part D is a four-tier structure, according to the report "Understanding the 2006 Medicare Part D Marketplace."

The report says that at least 51 percent of stand-alone PDPs and at least 63 percent of MA-PD plans have at least four coverage tiers, compared with an average of three tiers for commercial plans.

"This is reflective of the willingness of these plans to enter this new marketplace and to control costs," says Lindsey Spindle, a spokeswoman for Avalere Health, the consulting company that issued the report. "If plans are placing drugs in the fourth tier, it's clearly an attempt to control costs. We're seeing that, along with the use of prior authorization, step therapy, an increase in generic utilization, or some other cost control means," says Spindle.

In general, lower tiers tend to have flat copayment amounts and higher tiers carry a percentage coinsurance; overall cost-sharing amounts are high relative to commercial offerings. Beneficiaries will face significant cost sharing increases when buying products in higher tiers.

"For beneficiaries, this is such new territory," says Spindle. "People will choose their plan based on premium price and then drug coverage. But what happens in the future, if the beneficiary needs a drug that is in a higher tier? They could be in for a surprise," Spindle says.

Among PDPs and MA-PD plans, four or more tiers is very common.

Source: Avalere Health

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There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

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The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.