Coverage and Payment
Coverage and reimbursement shapes patient access and affordability. Life sciences companies rely on favorable coverage decisions to ensure market access and adoption of their products, while health plans need effective reimbursement strategies to manage costs and provide comprehensive benefits to their members.
2025 Part D Formularies Shift to More Coinsurance and UM
While the share of drugs covered on Part D formularies will increase slightly in 2025, more drugs will have coinsurance and utilization management.
Mental Health Parity Rule: Industry Reactions and Implications
Stakeholders are contending with a new rule implementing stricter requirements on mental health care parity to ensure patient coverage and enhance equity.
Accelerating Access through Payer Marketing
Payer marketing requires a strategic approach that combines data and storytelling to communicate product value and differentiation and ensure patient access.
SNF 3-Day Waiver Use at the End of the COVID-19 Public Health Emergency
Use of the three-day waiver was stable over the course of the pandemic, though shifts in admission sources were observed.
125,000 in MS Could Gain Medicaid Coverage Through Expansion
If Mississippi expands Medicaid to 138% federal poverty level, Avalere estimates 125,000 uninsured individuals, ages 19-64, could gain coverage in 2025.
CMS Expands Medicare Device Access Via New TCET Pathway
The new Transitional Coverage for Emerging Technologies pathway will provide Medicare coverage for up to five FDA-designated Breakthrough Devices per year.
Formulary Coverage and Access Shifts in 2024 PDPs
Avalere analysis shows that there are substantial changes and variations in PDP formularies at the therapeutic area and regional levels from 2023 to 2024.
New Avalere Resource: Coverage and Coding Regulatory Calendar
Avalere’s new CY 2024–2025 Coding and Regulatory Calendar supports life sciences firms’ strategic planning for critical coding deadlines, timelines, and regulatory updates.
More Low-Income Subsidy Enrollees Pay Part D Premiums in 2024
An Avalere analysis finds that from 2023 to 2024 the number of LIS enrollees paying a Part D premium increased by more than 1 million enrollees.
2025 a Unique Year for MA and Part D Plans’ Rebate Reallocation
Given increased plan liability under the IRA and uncertainty from late changes to Star Ratings, plans should strategize for their Rebate Reallocation process.
Health Plans 2030: Shifting Clinical Care Delivery
The second installment of our Health Plan series examines how clinical care will shift in reaction to changes in demographics, technology, and environmental factors.
A Deep Dive Into Hospice Utilization Trends
Avalere analysis reveals an opportunity to support more Medicare beneficiaries with hospice care, as evolving diagnoses and ALOS prompt reevaluation of program metrics
Patterns in Patient Access to MS Drugs
Avalere analysis finds that less clinically efficacious MS drugs have better coverage, more advantageous tiering, and lower UM compared to more efficacious drugs.
MA Plans Increase Use of Step Therapy for Part B Drugs
In 2023, 54% of Medicare Advantage enrollees were in plans that required step therapy for 10 commonly used rheumatoid arthritis drugs covered under Part B.
Medicaid Managed Care Rule: Three Things Plans Should Know
CMS’s new Medicaid and CHIP managed care rule will impact wait time standards, In Lieu of Service and Setting usage, and quality rating.
Health Plans 2030: Evolving Operational Approaches
The first installment of our Health Plans series explains how plans can evolve their approaches to provider contracting and utilization management for the future.
Innovation Spurs Growth in Medicare NTAP
Recent growth in the NTAP designation alters dynamics for manufacturers considering pursuing the designation for new technologies.
2024: An Era of Innovation and Disruption in Kidney Care
A dynamic regulatory landscape, technological advancements, and investments in R&D offer new opportunities and challenges in kidney care.
CMS Creates New Codes to Reimburse for Navigation Services
Newly developed HCPCS codes will support increased access to oncology navigation services, which have been shown to improve patient outcomes.
Trends in Risk Adjustment Coding Operations
Plans adapt to market changes in risk adjustment coding. Interviews with plan professionals reveal three trends for efficiency, effectiveness, and compliance.