Regulatory and Policy Changes
This state recently passed legislation to mandate that copay card dollars track to the accumulators.
What is Iowa?
This is genetic-based testing that is becoming standard of care to help patients get the right drug the first time.
What is pharmacogenomics?
These 3 retail chains are closing locations due to access and market changes.
What are Walgreens, CVS, and Rite Aid?
PBMs with this model pass through rebates and charge admin fees.
What is a transparent PBM?
True Rx has implemented this technology to read prior authorizations to ease our PA pharmacist’s workflow.
What is AI?
These are due to go into effect in August 2025 and will increase the price of internationally sourced medications.
What are pharmaceutical tariffs?
Although FDA-approved indications currently include type 2 diabetes and obesity management, this drug class has emerging indications such as heart failure, polycystic ovarian syndrome, Alzheimer's, and substance abuse disorder.
What are GLP-1s?
This Shark Tank personality launched a low-cost generic pharmacy.
Who is Mark Cuban?
This is occurs when the PBM charges the employer more for the medications filled on the plan than what they paid the manufacturer.
What is spread pricing?
AWP, WAC, MAC, NADAC, and U&C fall under this umbrella.
What are pricing models for adjudication?
This is an assessment done each year where insurance providers compare their prescription coverage to Medicare Part D standards. If it meets or exceeds Part D in value, they notify you in writing.
What is creditable coverage?
Once for type II diabetes, this drug is being prescribed off label and used for weight loss.
What is Ozempic?
Medications from this channel are 2–5x cheaper than retail pharmacy.
What is international sourcing?
Employers are switching to this model for more control over spend.
What is self-funded?
On December 20, 2024, the FDA approved this drug for the treatment of moderate to severe obstructive sleep apnea in adults with obesity, to be used in combination with a reduced calorie diet and increased physical activity.
What is Zepbound?
U.S. federal program requiring manufacturers to offer reduced drug pricing to eligible providers.
What is 340B?
These lower-cost alternatives to biologics, like Hadlima, are on the rise.
What are biosimilars?
75% of new drugs in development belong to this high-cost category.
What are specialty drugs?
Insurer owned by a healthcare org to self-insure rather than buy commercial coverage.
What is a captive?
This is a post-dispensing discount paid by drug manufacturers to PBMs or plans.
What is a rebate?
This federal transparency rule now requires health plans to publicly disclose negotiated rates and historical net prices for prescription drugs.
What is the Transparency in Coverage Rule?
Zolgensma is an example of this medication class with a total cost of over 1 million dollars per fill.
What is gene therapy?
This model disrupts traditional retail pharmacy by shipping generic drugs directly to consumers at cost plus a fixed margin.
What is the Cost Plus Drug model?
This model removes the PBM as the middleman and allows employers to negotiate drug pricing directly with manufacturers and pharmacies.
What is a direct-to-contract model?
Many PBMs are adopting this tech-driven model to guide plan design and steer members to cost-effective therapies.
What is formulary management?