Federal rules could streamline prior authorization decisions…but not for drugs

A CMS proposed rule would expedite the prior authorization approval process. CMS summarizes key provisions of the rule as follows: Proposals include requiring implementation of a Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) standard Application Programming Interface (API) to support electronic prior authorization. They also include requirements for certain payers to include a specific reason…

Barriers to Fair Access

Last month, ICER released their 2023 “Assessment of Barriers to Fair Access” . The report concludes the following regarding 18 drugs evaluated. ICER defines “fair access” based on the following criteria: Cost sharing Cost sharing based on net price. Patient cost sharing should be based on the net price to the plan sponsor, not the…

How restrictive are Medicare Advantage plans?

Now that 51% of Medicare beneficiaries are enrolled in Medicare Advantage (MA), one key question is how restrictive are MA narrow networks? While beneficiaries enrolled in Medicare fee-for-service can choose any provider, MA plans can impose restrictions on enrollee’s provider choices. Measuring how restrictive an MA plan is, however, is difficult because “restrictiveness” is a…

Inequities in exposure to copay accumulator programs

Copay cards are somewhat controversial. These cards or coupons are used to help patients afford copayments and deductible payments patients owe when using pharmaceuticals. On the one hand, these programs are highly beneficial for patients. Patient out-of-pocket costs have risen dramatically in recent years, even among the insured. For instance, whereas only 7% of workers…

Insurance Obstacles in America

As reported based on a N.Y. Times/KFF survey: A majority of Americans with health insurance said they had encountered obstacles to coverage, including denied medical care, higher bills and a dearth of doctors in their plans… About 40 percent of those surveyed said they had delayed or gone without care in the last year because…

White vs. Brown vs. Clear Bagging

In 2020, spending on specialty drugs was $265 billion; this constituted 49.6% of total prescription drug expenditure. To combat rising costs, payers have turned to white, brown and clear bagging as well as approaches to restrict the site of care where patients receive specialty drugs. What are these “bagging” policies, what are the pros and…