When managing pharmacy benefits, one of the least transparent practices utilized by many Pharmacy Benefit Managers (PBMs) is the use of multiple Maximum Allowable Cost (MAC) lists. This tactic, while complex, can significantly affect plan sponsors, especially Benefit Directors, employee benefit brokers, and PBM consultants, by inflating costs and undermining transparency.

What are MAC Lists?

A MAC list is a pricing benchmark used by PBMs to determine the maximum amount a plan will pay for generic drugs and in some cases multisource brand drugs. Ideally, a single, well-structured MAC list should set a consistent reimbursement rate, ensuring fair pricing across pharmacies. However, some PBMs use multiple MAC lists, which is where the problem begins.

The Downside of Multiple MAC Lists

When PBMs deploy multiple MAC lists, each pharmacy or pharmacy network may be reimbursed differently for dispensing the same drug. For example, chain pharmacies might receive higher reimbursements than independent pharmacies for the same generic drug, despite all pharmacies purchasing from similar wholesalers.

A real-world example that illustrates this disparity comes from a recent audit of Mississippi’s commercial prescription drug claims for the calendar year 2022. The audit revealed that a large PBM used 49 distinct MAC lists, with specific lists exclusively applied to chain or independent pharmacies. On average, independent pharmacies were reimbursed 74% less than chain pharmacies for the same drugs. This discrepancy highlights how PBMs manipulate MAC lists to inflate costs for plan sponsors while benefiting select pharmacies.

For Benefit Directors and PBM consultants, the practice of using multiple MAC lists means that PBMs have more room to game the system. Costs that appear controlled on paper may actually be much higher due to varying reimbursement rates. Furthermore, this approach allows PBMs to mask their true margins, making it difficult for plan sponsors to understand where their money is going.

Increased Costs and Lack of Transparency

One of the most significant issues with multiple MAC lists is the lack of transparency. Each list is proprietary, meaning plan sponsors have no way of verifying how much pharmacies are reimbursed or comparing costs across networks. As a result, plan sponsors can find themselves paying more for generic drugs without realizing it, especially if their PBM reimburses affiliate or chain pharmacies at higher rates than independents, as demonstrated in the Mississippi Board of Pharmacy audit.

For example, in the same audit, generic azithromycin was reimbursed at vastly different rates: one independent pharmacy was reimbursed at only 122% of the lowest chain pharmacy reimbursement, while an affiliate pharmacy received 833.3%. These hidden costs accumulate over time, leading to higher overall drug spend, which is then passed on to the plan sponsor.

The Fiduciary PBM Model: A Transparent Alternative

In contrast to this opaque practice, a fiduciary PBM model ensures that the PBM is aligned with the client’s best interests. A fiduciary PBM operates under a legal obligation to manage costs and prioritize transparency. There are no hidden markups, and reimbursement rates are consistent across all pharmacy networks, ensuring that plan sponsors can trust that the lowest price is always being paid for a given drug.

How Fiduciary PBMs Keep Costs Down

• One Transparent MAC List: Fiduciary PBMs utilize a single, transparent MAC list, applying uniform rates across all pharmacies, which eliminates the possibility of hidden profit margins through inflated reimbursement rates.
• Accountability: By adhering to a fiduciary standard, these PBMs must disclose any conflicts of interest and ensure that they do not profit at the client’s expense.
• Cost Control: With the fiduciary model, PBMs are incentivized to actively control drug costs and improve outcomes rather than focusing on maximizing their own margins. This leads to more predictable and often lower drug spend for employers.

Conclusion

For Benefit Directors, employee benefit brokers, and PBM consultants, the use of multiple MAC lists by traditional PBMs presents a significant risk in terms of increased costs and lack of transparency. In contrast, the fiduciary PBM model offers a clear path to managing pharmacy benefits with alignment, cost control, and accountability. By choosing a fiduciary PBM, plan sponsors can ensure that they are paying fair and consistent prices for medications, ultimately protecting their bottom line.

The key takeaway here is clear: when evaluating PBM options, understanding the intricacies of MAC list usage can be the difference between controlling costs or unknowingly inflating them.

Supreme Court takes up PBM case: Does ERISA preempt states’ efforts to regulate drug prices and other notes from around the interweb:

• Supreme Court takes up PBM case: Does ERISA preempt states’ efforts to regulate drug prices? The U.S. Supreme Court plans to look at states’ ability to regulate pharmacy benefit managers this term. Glen Mulready, Oklahoma’s insurance commissioner, is trying to overturn an appeals court ruling that found that the Employee Retirement Income Security Act of 1974 benefits rule uniformity provisions preempt state efforts to regulate PBMs when the PBMs are serving self-funded employer health plans. The Supreme Court “has long cautioned against stretching ERISA to preempt laws in ‘traditionally state-regulated’ areas about which ‘ERISA has nothing to say,’” Mulready says in a brief filed in connection with the case, Mulready v. Pharmaceutical Care Management Association. “Pharmacy regulation is an area of traditional state concern and neither PBMs nor prescription-drug benefits are mentioned anywhere in ERISA.” But the PCMA, the PBMs’ group, says ERISA should preempt the Oklahoma PBM law.

• What Went Wrong: How Formularies, Contracts, and Rebates Created a Headwind for Biosimilars. The promise of biosimilars was supposed to be simple: more competition, lower costs and better access for patients. Yet as the dust settles from the introduction of adalimumab biosimilars following Humira’s (AbbVie) patent expiration at long last, it’s clear that formularies have become one of the biggest barriers to realizing the cost-saving potential of biosimilars. When adalimumab-atto (Amjevita; Amgen), the first biosimilar for adalimumab, launched, its adoption was alarmingly low.1 As other biosimilars entered the market in quick succession, hopes were high that price competition would soon follow. But the market manipulation enabled by formulary management has instead slowed down the entire process by creating significant headwinds.

• Employers haven’t a clue how their drug benefits are managed. Most employers have little idea what the pharmacy benefit managers they hire do with the money they exchange for the medications used by their employees, according to a KFF survey released Wednesday morning. In KFF’s latest employer health benefits survey, company officials were asked how much of the rebates collected from drugmakers by pharmacy benefit managers, or PBMs, is returned to them. In recent years, the pharmaceutical industry has tried to deflect criticism of high drug prices by saying much of that income is siphoned off by the PBMs, companies that manage patients’ drug benefits on behalf of employers and health plans. Employers may assume the PBMs are acting in their best interest, but they don’t have a legal obligation to do so.

• PBM 101: Manufacturer Copay Assistance Programs. Alternate Funding Programs, such as copay assistance programs (CAPs), are offered by manufacturers on some brand name medications to lower patients’ out-of-pocket costs. While the focus is on removing barriers, if not managed, these programs can circumvent the formulary and the plan design’s ability to steer members toward lower cost and effective therapies. In response, Pharmacy Benefit Managers (PBM) have developed programs that plan sponsors can opt into. PBMs either manage their own programs or outsource all or a portion of their programs. One such program is manufacturer copay assistance programs. CAPs are non-need-based programs for those on commercial or private insurance. PBMs typically manage CAP in two ways: accumulator programs and/or variable copay programs.

Pharmacy Benefit Managers (PBMs) have a significant role in managing prescription drug plans for employers, brokers, and benefits consultants. However, the lack of transparency in their operations often leaves organizations in the dark about the true costs tied to their pharmacy benefits. That’s where our webinar, Unlocking the Secrets of PBMs: Strategies to Navigate Their Profit Tactics, can help. It provides an in-depth look at how PBMs operate and gives you the insights needed to better control your pharmacy expenses.

During this session, we explore strategies designed to help employers, brokers, and consultants spot and address hidden profit tactics that inflate costs. PBMs often use complex pricing, hidden fees, and undisclosed rebate agreements, which can significantly drive up the cost of benefits. Attendees will learn how to recognize these tactics and implement strategies to mitigate their financial impact.

One major takeaway from the webinar is the value of adopting a fiduciary standard of care. Unlike traditional PBM models, which focus on profit, a fiduciary PBM puts the plan sponsor and its members first. This approach not only ensures ethical business practices but also helps reduce costs without sacrificing patient care. We’ll highlight real-world examples showing how fiduciary PBMs make a difference in controlling costs.

Additionally, the webinar offers practical tips for negotiating better contracts, optimizing formulary management, and using data analytics for informed decision-making. These strategies will help you create a more transparent, cost-effective pharmacy plan tailored to your organization. With these tools, you can ensure every dollar spent on pharmacy benefits brings value to both your organization and your members.

If you’re an employer, broker, or consultant aiming to reduce pharmacy costs while maintaining high-quality care, this webinar is essential. Learn from industry experts who have been deeply involved in PBM negotiations and cost management. Take the first step toward a more transparent and patient-centered pharmacy benefit strategy by watching Unlocking the Secrets of PBMs: Strategies to Navigate Their Profit Tactics today.

How Formularies, Contracts, and Rebates Created a Headwind for Biosimilars and other notes from around the interweb:

• What Went Wrong: How Formularies, Contracts, and Rebates Created a Headwind for Biosimilars. The promise of biosimilars was supposed to be simple: more competition, lower costs and better access for patients. Yet as the dust settles from the introduction of adalimumab biosimilars following Humira’s (AbbVie) patent expiration at long last, it’s clear that formularies have become one of the biggest barriers to realizing the cost-saving potential of biosimilars. When adalimumab-atto (Amjevita; Amgen), the first biosimilar for adalimumab, launched, its adoption was alarmingly low.1 As other biosimilars entered the market in quick succession, hopes were high that price competition would soon follow. But the market manipulation enabled by formulary management has instead slowed down the entire process by creating significant headwinds.

• Employers haven’t a clue how their drug benefits are managed. Most employers have little idea what the pharmacy benefit managers they hire do with the money they exchange for the medications used by their employees, according to a KFF survey released Wednesday morning. In KFF’s latest employer health benefits survey, company officials were asked how much of the rebates collected from drugmakers by pharmacy benefit managers, or PBMs, is returned to them. In recent years, the pharmaceutical industry has tried to deflect criticism of high drug prices by saying much of that income is siphoned off by the PBMs, companies that manage patients’ drug benefits on behalf of employers and health plans. Employers may assume the PBMs are acting in their best interest, but they don’t have a legal obligation to do so.

• Kentucky sues PBM, alleging it had a role in the deadly opioid addiction crisis. The lawsuit Attorney General Russell Coleman filed this week in state court claims St. Louis-based Express Scripts and its affiliated organizations colluded with opioid manufacturers in deceptive marketing schemes to increase sales of the addictive drugs. The result was an epidemic of “overdose and death caused by an oversupply of opioids flooding communities from powerful corporations who sought to profit at the expense of the public,” the suit says. Express Scripts responded Friday that it has long worked to combat opioid overuse and abuse and will “vigorously contest these baseless allegations in court.” Government lawsuits against pharmacy benefit managers are the latest frontier – and maybe the last big one – in years of litigation over the worst drug epidemic the U.S. has ever experienced. The class of drugs is linked to about 75,000 deaths in the U.S. in the 12 months that ended April 30.

• PBM 101: Manufacturer Copay Assistance Programs. Alternate Funding Programs, such as copay assistance programs (CAPs), are offered by manufacturers on some brand name medications to lower patients’ out-of-pocket costs. While the focus is on removing barriers, if not managed, these programs can circumvent the formulary and the plan design’s ability to steer members toward lower cost and effective therapies. In response, Pharmacy Benefit Managers (PBM) have developed programs that plan sponsors can opt into. PBMs either manage their own programs or outsource all or a portion of their programs. One such program is manufacturer copay assistance programs. CAPs are non-need-based programs for those on commercial or private insurance. PBMs typically manage CAP in two ways: accumulator programs and/or variable copay programs.

As pharmacy benefit managers (PBMs) and health plan sponsors face increasing pressure to manage costs without compromising care, one of the most effective strategies is moving J code drugs from medical to pharmacy benefit. This approach can streamline administration, increase transparency, and create more predictable pricing structures for stakeholders. In this blog, we’ll explore the benefits of this transition, and I’ll explain the key differences between HCPCS and NDC codes through a simple table.

Understanding J Code Drugs

J codes are part of the Healthcare Common Procedure Coding System (HCPCS), which healthcare providers use to bill for injectable drugs, chemotherapy, and other treatment medications administered in clinical settings. When billed under the medical benefit, these drugs often come with opaque pricing and limited oversight, making it difficult for plan sponsors to manage costs effectively.

Benefits of Moving J Code Drugs to the Pharmacy Benefit

1. Increased Cost Transparency: Under the medical benefit, drugs billed using J codes tend to come with variable pricing due to fee-for-service models and markups from healthcare providers. In contrast, the pharmacy benefit utilizes National Drug Codes (NDC), which allow for more standardized and transparent pricing, enabling better cost management and forecasting.
2. Better Clinical Management: Pharmacy benefits offer a structured formulary, prior authorization requirements, and utilization management tools that ensure members receive the most appropriate medication. With J code drugs under the pharmacy benefit, plan sponsors can implement these clinical management techniques to control utilization and promote evidence-based medicine.
3. Streamlined Claims Processing: Medical benefit claims often come with delayed payments and higher administrative complexity. By moving these drugs to the pharmacy benefit, plan sponsors can leverage electronic processing, reducing delays and ensuring more accurate reimbursement.
4. Specialty Pharmacy Expertise: Many J code drugs are high-cost specialty medications. When these drugs are shifted to the pharmacy benefit, they can be managed through specialty pharmacies that offer tailored support services like patient education, adherence programs, and risk management.
5. Mitigation of Fraud, Waste, and Abuse: The move from HCPCS to NDC coding allows for more granular data tracking, making it easier to identify potential instances of overbilling, upcoding, or inappropriate use. Pharmacy benefits also have stricter audit protocols, which can help reduce the risk of fraud.

Final Thoughts

Start by analyzing historical claims data for J code drugs under the medical benefit. Identify high-cost drugs, their utilization patterns, and the settings where they are administered (e.g., hospitals, outpatient centers). This will allow you to prioritize which drugs to transition first, focusing on those that offer the greatest potential for cost savings and clinical oversight when moved to the pharmacy benefit.

Moving J code drugs from medical to pharmacy benefit is a practical and strategic move for organizations looking to take control of rising specialty drug costs. Not only does this shift offer better financial transparency, but it also enhances clinical oversight and provides a framework for reducing inefficiencies. By leveraging the advantages of NDC-based drug management, plan sponsors can deliver better outcomes for patients while ensuring a more predictable and manageable cost structure.

Employers seeking to avoid cost-shifting even as expenses continue to rise and other notes from around the interweb:

• Employers seeking to avoid cost-shifting even as expenses continue to rise. As employers face rising costs, many are looking to rethink plan designs rather than emphasize shifting expenses to workers, according to a new WTW report. WTW released its 2024 Best Practices in Healthcare Survey on Thursday, which polled 417 employers representing 6 million workers. It found that these firms are expecting costs to balloon by 7.7% in 2025, compared to an increase of 6.9% in 2024 and 6.5% for 2023. Despite the increase, however, only 34% told WTW that they intend to shift those costs to employees by raising premiums. Twenty percent said they will push high-deductible health plans or account-based coverage to address costs. Instead, 52% said they intend to roll out programs that reduce total costs, and 51% said they would use plan designs and network models to steer workers to lower-cost and higher-quality providers.

• Monopoly Round-Up: Lina Khan, Pharma Middlemen and “Tasty Rebates”. By 2019, Sanofi was giving OptumRx, one of the biggest PBMs, 80% of the list price of Lantus just to be the preferred insulin for its patients. That’s just $64 going to Sanofi for the drug, and $339 going to OptumRx as a refund. Now, you might think that’s not a big deal. I mean, a PBM works for an insurance company, and you would think insurance companies have an incentive to keep pharma prices low. After all, insurance companies take a monthly payment from patients, and then pay for most medical expenses. A drug cost is an expense; therefore they’d like that to be lower. So, you’d imagine that the $339 refund is just a way of lowering the price to the patient. But here’s where it gets nasty.

• Kentucky sues PBM, alleging it had a role in the deadly opioid addiction crisis. The lawsuit Attorney General Russell Coleman filed this week in state court claims St. Louis-based Express Scripts and its affiliated organizations colluded with opioid manufacturers in deceptive marketing schemes to increase sales of the addictive drugs. The result was an epidemic of “overdose and death caused by an oversupply of opioids flooding communities from powerful corporations who sought to profit at the expense of the public,” the suit says. Express Scripts responded Friday that it has long worked to combat opioid overuse and abuse and will “vigorously contest these baseless allegations in court.” Government lawsuits against pharmacy benefit managers are the latest frontier – and maybe the last big one – in years of litigation over the worst drug epidemic the U.S. has ever experienced. The class of drugs is linked to about 75,000 deaths in the U.S. in the 12 months that ended April 30.

• PBM 101: Manufacturer Copay Assistance Programs. Alternate Funding Programs, such as copay assistance programs (CAPs), are offered by manufacturers on some brand name medications to lower patients’ out-of-pocket costs. While the focus is on removing barriers, if not managed, these programs can circumvent the formulary and the plan design’s ability to steer members toward lower cost and effective therapies. In response, Pharmacy Benefit Managers (PBM) have developed programs that plan sponsors can opt into. PBMs either manage their own programs or outsource all or a portion of their programs. One such program is manufacturer copay assistance programs. CAPs are non-need-based programs for those on commercial or private insurance. PBMs typically manage CAP in two ways: accumulator programs and/or variable copay programs.

The Federal Trade Commission (FTC) has filed a significant complaint against some of the largest pharmacy benefit managers (PBMs), including Caremark, Express Scripts, and OptumRx, along with their group purchasing organizations (GPOs). The FTC claims these PBMs are driving up prescription drug costs by manipulating price competition, particularly for critical drugs like insulin.

For self-insured employers, employee benefit brokers, and pharmacy benefit consultants, this case is particularly relevant because it highlights how PBMs’ practices directly impact the cost of your pharmacy benefits. The complaint points out that PBMs have been leveraging their control over drug formularies—lists that determine which drugs are covered and at what price—to demand increasingly higher rebates from drug manufacturers. This approach has led to artificially inflated list prices, which hit patients with high deductibles or co-insurance hardest, forcing many to pay more out-of-pocket.

• PBM Rebate Practices Inflate Drug Prices: PBMs prioritize rebates from drug manufacturers over lowering actual drug costs, leading to higher list prices, particularly for life-saving medications like insulin. This increases costs for self-insured employers and their members.

• Restrictive Formularies Drive Up Costs: PBMs are using exclusionary formularies to negotiate higher rebates, which can lead to employees paying more out-of-pocket for their prescriptions, especially those with high-deductible health plans or coinsurance.

• Impact on Self-Insured Plans: The manipulation of drug pricing by PBMs forces self-insured employers to bear the brunt of inflated pharmacy benefit costs, making it harder to control overall healthcare spending.

• Transparency and Fiduciary Oversight Are Critical: The FTC’s complaint highlights the need for PBM reform. Employers and consultants should push for PBM contracts that ensure transparency, rebate pass-through, and fiduciary responsibility to align incentives with cost control.

• Opportunity to Reassess PBM Relationships: This is an ideal time for employers and brokers to reevaluate PBM contracts, focusing on fiduciary models that prioritize lower net drug prices, transparency, and the well-being of plan members over rebate maximization.

PBMs have introduced restrictive formularies that exclude certain medications to extract larger rebates, instead of focusing on lowering the net cost of medications. Insulin, a life-saving medication for millions of Americans, has seen skyrocketing list prices due to this rebate-driven model. As a result, employers, brokers, and consultants are left managing higher pharmacy benefit costs, while employees bear a greater financial burden, which can ultimately drive up total healthcare costs due to non-adherence to essential medications.

The FTC’s complaint underscores the need for more transparency and a shift away from rebate-driven strategies that inflate drug prices. For self-insured employers and those advising them, understanding how PBM practices affect the total cost of care is crucial. The FTC is pushing for reforms that could lead to better control over drug pricing, greater transparency, and reduced out-of-pocket costs for employees—key factors in managing a more sustainable and cost-effective pharmacy benefit plan.

This is a pivotal moment to reassess PBM contracts, focusing on true fiduciary models that prioritize cost-saving and transparency for plan sponsors and their members.

Pharmaceutical Strategies Group Publishes 2024 Pharmacy Benefit Manager Customer Satisfaction Report and other notes from around the interweb:

• Pharmaceutical Strategies Group Publishes 2024 Pharmacy Benefit Manager Customer Satisfaction Report. The 2024 Pharmacy Benefit Manager Customer Satisfaction Report published by Pharmaceutical Strategies Group (“PSG”) disclosed low satisfaction and demand for change in the industry amongst healthcare payers. This report is the most comprehensive research on pharmaceutical benefit managers (PBMs), with a comprehensive look into the increasingly complex structures and functions of today’s marketplace. The report, published for more than two decades, offers decision makers powerful comparative intelligence to help in the selection and management of services provided by PBMs. PSG’s deep understanding of the marketplace enables a broader view of the arrangements PBMs use to meet the unique priorities of plan sponsors. “PBMs are experiencing increased pressure that is ultimately going to drive change in the coming years,” said Morgan Lee, PhD, MPH, CPH, Senior Director of Research & Strategy at PSG. “This year’s report pulls back the curtain on healthcare payers’ appetite for disruption and the barriers and hesitancy posing roadblocks. Overwhelmingly, there is dissatisfaction with the status quo, but what degree of transformation the industry will undergo in the coming years remains to be seen.”

• Express Scripts Sues FTC, Demands Withdrawal of PBM Report. In a lawsuit filed in federal court in Missouri, Express Scripts by Evernorth, a subsidiary of The Cigna Group (NYSE: CI), demanded that the Federal Trade Commission (“FTC” or the “Commission”) retract its July 2024 report, which is filled with false and misleading claims about the pharmacy benefit management (PBM) industry and fails to serve the interests of American consumers. Information about Express Scripts’ lawsuit to protect those it serves is available at https://www.evernorth.com/advocate. “The FTC has taken unconstitutional actions in publishing a report that ignores the evidence provided by our company and other PBMs, demonstrates clear ideological bias and advances a false and damaging narrative – a narrative that could harm the health care system by removing essential checks and balances which would result in higher drug prices for American consumers,” said Andrea Nelson, Chief Legal Officer for The Cigna Group. “We don’t take this step lightly, but as advocates working to lower drug prices for millions of Americans and the employers, labor unions, and government agencies that provide their prescription drug benefits, we cannot let the FTC’s unlawful actions and false information stand.”

• Walgreens paying $106.8 million to settle US prescription billing fraud charges. Walgreens Boots Alliance (WBA.O), agreed to pay $106.8 million to settle charges it fraudulently billed the U.S. government for prescriptions that were never dispensed, the Department of Justice said on Friday. The Justice Department said Walgreens violated the federal False Claims Act between 2009 and 2020 by submitting payment claims to Medicare, Medicaid, and other healthcare programs for prescriptions it processed but which were never picked up. This caused the pharmacy chain to receive tens of millions of dollars for prescriptions it never provided to patients, the department said. “Federal health care programs provide critical health care services to millions of Americans,” said Brian Boynton, head of the Justice Department’s civil division. “We will hold accountable those who abuse these programs by knowingly billing for goods or services they did not provide.

• Copay Adjustment Chess Match: What Will Payers Do Next?. The primary reason that payers created copay adjustment programs lies within the very nature of their business, namely that insuring patients means taking on the risk of patients’ lives for the pharmaceutical benefit. Additionally, the payers’ clients—employers—demand that payers and pharmacy benefit managers (PBMs) keep drug costs under control since the cost of providing healthcare to their employees remains high. Over the years, formularies, exclusions, and prior authorizations have been created to support this cost control, but using the accumulator technique, in which the patient’s annual out-of-pocket (OOP) maximum is affected by taking off the manufacturer’s contribution, is a newer approach. It all stems from the same reasoning—payers are seeking ways to control costs to benefit their bottom line, while employers are seeking ways to control the costs of providing healthcare to their employees.

Express Scripts Sues FTC, Demands Withdrawal of PBM Report and other notes from around the interweb:

• Express Scripts Sues FTC, Demands Withdrawal of PBM Report. In a lawsuit filed in federal court in Missouri, Express Scripts by Evernorth, a subsidiary of The Cigna Group (NYSE: CI), demanded that the Federal Trade Commission (“FTC” or the “Commission”) retract its July 2024 report, which is filled with false and misleading claims about the pharmacy benefit management (PBM) industry and fails to serve the interests of American consumers. Information about Express Scripts’ lawsuit to protect those it serves is available at https://www.evernorth.com/advocate. “The FTC has taken unconstitutional actions in publishing a report that ignores the evidence provided by our company and other PBMs, demonstrates clear ideological bias and advances a false and damaging narrative – a narrative that could harm the health care system by removing essential checks and balances which would result in higher drug prices for American consumers,” said Andrea Nelson, Chief Legal Officer for The Cigna Group. “We don’t take this step lightly, but as advocates working to lower drug prices for millions of Americans and the employers, labor unions, and government agencies that provide their prescription drug benefits, we cannot let the FTC’s unlawful actions and false information stand.”

• Walgreens paying $106.8 million to settle US prescription billing fraud charges. Walgreens Boots Alliance (WBA.O), agreed to pay $106.8 million to settle charges it fraudulently billed the U.S. government for prescriptions that were never dispensed, the Department of Justice said on Friday. The Justice Department said Walgreens violated the federal False Claims Act between 2009 and 2020 by submitting payment claims to Medicare, Medicaid, and other healthcare programs for prescriptions it processed but which were never picked up. This caused the pharmacy chain to receive tens of millions of dollars for prescriptions it never provided to patients, the department said. “Federal health care programs provide critical health care services to millions of Americans,” said Brian Boynton, head of the Justice Department’s civil division. “We will hold accountable those who abuse these programs by knowingly billing for goods or services they did not provide.”

• Elevance intensifies Ozempic crackdown. Anthem Blue Cross Blue Shield is requesting payments from some providers it alleges falsified patients’ medical records when prescribing Ozempic, Bloomberg reported Sept. 12. A spokesperson for Elevance Health, which owns Anthem BCBS, told Bloomberg it contacted a small number of providers about repayments for Ozempic prescribed to their patients. In some cases, the amount of repayment requested was more than $1 million. Representatives for Elevance told Bloomberg that Anthem BCBS only covers Ozempic for patients with Type 2 diabetes. The drug is not approved by the FDA for weight loss but is often prescribed off-label for that purpose. Ozempic is a prescription medication used to improve blood sugar control in adults with type 2 diabetes. It’s a once-weekly injection that also helps with weight loss by reducing appetite. Its active ingredient is semaglutide, a GLP-1 receptor agonist.

• Copay Adjustment Chess Match: What Will Payers Do Next?. The primary reason that payers created copay adjustment programs lies within the very nature of their business, namely that insuring patients means taking on the risk of patients’ lives for the pharmaceutical benefit. Additionally, the payers’ clients—employers—demand that payers and pharmacy benefit managers (PBMs) keep drug costs under control since the cost of providing healthcare to their employees remains high. Over the years, formularies, exclusions, and prior authorizations have been created to support this cost control, but using the accumulator technique, in which the patient’s annual out-of-pocket (OOP) maximum is affected by taking off the manufacturer’s contribution, is a newer approach. It all stems from the same reasoning—payers are seeking ways to control costs to benefit their bottom line, while employers are seeking ways to control the costs of providing healthcare to their employees.

Pharmacy Benefit Managers (PBMs) play a crucial role in managing prescription drug benefits for employers, brokers, and benefits consultants. However, the lack of transparency in their operations often leaves many organizations struggling to fully understand the costs associated with their pharmacy benefits. This is where our webinar, Unlocking the Secrets of PBMs: Strategies to Navigate Their Profit Tactics, comes in—offering a deep dive into the opaque world of PBMs and equipping you with the knowledge to take control of your pharmacy spend.

The strategies we discuss in this session are designed to help employers, brokers, and benefits consultants identify and mitigate hidden profit tactics that can lead to inflated costs. PBMs often employ complex pricing structures, hidden fees, and undisclosed rebate arrangements that can significantly impact the overall cost of pharmacy benefits. By attending this webinar, you’ll learn how to spot these tactics and implement effective strategies to minimize their financial impact.

One of the key takeaways from this webinar is understanding the importance of a fiduciary standard of care. Unlike traditional PBM models that prioritize profits, a fiduciary approach ensures that the PBM acts in the best interest of the plan sponsor and its members. This approach not only aligns with ethical standards but also helps in achieving cost savings without compromising patient outcomes. We’ll explore real-world examples and case studies that highlight the difference a fiduciary PBM model can make in controlling pharmacy costs.

Additionally, the webinar covers actionable insights on negotiating better contracts, optimizing formulary management, and leveraging data analytics to make informed decisions. These strategies empower you to create a more transparent and cost-effective pharmacy benefits program tailored to your organization’s needs. By understanding how to navigate the PBM landscape, you can ensure that every dollar spent on pharmacy benefits delivers maximum value to your organization and your members.

For employers, brokers, and benefits consultants committed to reducing pharmacy costs while maintaining high-quality care, this webinar is a must-watch. Don’t miss out on the opportunity to learn from experts who have been on the front lines of PBM negotiations and cost management. Equip yourself with the knowledge and tools to challenge the status quo and drive meaningful change in your pharmacy benefits strategy.

Watch Unlocking the Secrets of PBMs: Strategies to Navigate Their Profit Tactics today and take the first step towards regaining control over your pharmacy spend. Your path to a more transparent, cost-effective, and patient-centered pharmacy benefit plan starts here.