Medicare Coverage of Anti-Obesity Medications and other notes from around the interweb:

• Medicare Coverage of Anti-Obesity Medications? The proposed reinterpretation of Medicare Part D coverage of anti-obesity medications may provide approximately 3.4 million Medicare beneficiaries who have obesity with access to these innovative therapies. Medicare coverage would reduce out-of-pocket costs for these prescription drugs by as much as 95 percent for some enrollees. Approximately four million adult Medicaid enrollees may also gain new access to these medications.

• Pharmacy Benefit Manager uses unallowable pricing model. Spread pricing occurs when a managed care organization (MCO) reimburses its pharmacy benefit manager (PBM) for a prescription at a higher rate than what the PBM pays the pharmacy. This discrepancy, representing the prescription cost, is prohibited under Medicaid rules. Medicaid mandates that MCOs reimburse PBMs only for the actual prescription cost while also paying a separate administrative fee to the PBM for managing the program.

• Ex-McKinsey partner pleads guilty to destroying records about work promoting opioids. The case followed years of investigations and litigation concerning the extent to which Purdue and other drugmakers contributed to a deadly opioid addiction epidemic in the U.S. The U.S. Centers for Disease Control and Prevention says nearly 727,000 opioid overdose deaths occurred from 1999 to 2022. Purdue is currently involved in court-ordered mediation to rework a multibillion-dollar civil settlement with states, local governments and others in bankruptcy proceedings after the U.S. Supreme Court “turned aside” its initial deal.

• How a Duty To Spend Wisely on Worker Benefits Could Loosen PBMs’ Grip on Drug Prices. Ann Lewandowski knows all about pharmacy benefit managers, or PBMs, the companies that shape the U.S. drug market. Her job, as a policy advocate at drugmaker Johnson & Johnson, was to tell patient and physician groups about the PBMs’ role in high drug prices. Armed with that knowledge, Lewandowski filed a potentially groundbreaking lawsuit in February. Rather than targeting the PBMs, however, she went after a big company that uses one — her own employer, Johnson & Johnson. Lewandowski charges in her lawsuit that by contracting with the PBM Express Scripts, which is part of the insurance giant Cigna, Johnson & Johnson — which fired her in April — failed in its duty to ensure reasonable drug prices for its more than 50,000 U.S. employees.

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At TransparentRx, we specialize in delivering fiduciary pharmacy benefit management services that prioritize transparency, cost containment, and optimal patient outcomes. Our unique approach helps self-funded employers, benefits consultants, and health plan sponsors navigate the complexities of pharmacy benefits while reducing costs and enhancing care.

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