Regulatory and Policy Changes
This state recently passed legislation to mandate that copay card dollars track to the accumulators.
What is Iowa?
Genetic-based testing 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?
This tech reads prior auths to ease the 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?
This drug class is now used for heart failure, PCOS, Alzheimer’s, and more.
What are GLP-1s?
This Shark Tank personality launched a low-cost generic pharmacy.
Who is Mark Cuban?
This is the difference between what a PBM pays vs. charges an employer.
What is spread pricing?
AWP, WAC, MAC, NADAC, and U&C fall under this umbrella.
What are pricing models for adjudication?
Each year, the insurers compare coverage to Medicare Part D and notify if it meets or exceeds standards.
What is creditable coverage?
Once for type II diabetes, this drug is now FDA-approved 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?
Zolgensma, costing over $1M per fill, is this type of therapy.
What is gene therapy?
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?
Pharmacy benefit managers and plan sponsors are watching this trend, where gene and cell therapies are reimbursed based on patient outcomes.
What is outcomes-based reimbursement?
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?