Drug Pricing and Affordability

Keep up with our comprehensive coverage of administrative and legislative activity and what it means for industry, plans, providers, and patients.

Mark Gooding

Copay Accumulator and Maximizers: Evolving Policy Landscape

Implementation of copay accumulator and maximizer programs continues to increase; recent policy provisions finalized through federal rulemaking and state-level legislation have created new uncertainty for the future of these programs and the stakeholders they affect.

MFN Model Would Have Had a Major Impact on Certain Providers

New Avalere analysis finds that the the Most Favored Nation (MFN) Model would have a significant negative impact on Medicare providers that furnish Part B drugs—especially in oncology and rheumatology—and those in rural areas.

Podcast: Most Favored Nation Model Stakeholder Considerations

Tune into another episode of Start Your Day with Avalere. In this segment, experts from Avalere’s Policy practice discuss the Most Favored Nation (MFN) drug pricing model, how it works, and the implications for stakeholders.

Most Favored Nation Rule’s Impact on Medicare Beneficiaries OOP Costs

New Avalere analysis finds that most Medicare fee-for-service (FFS) beneficiaries would not see a substantial reduction in their out-of-pocket (OOP) costs as a result of the Most Favored Nation (MFN) model.

Avalere Statement on Trump Administration Drug Pricing Reforms

Earlier today, the Trump Administration released long-anticipated drug pricing reforms, including rules related to a Most Favored Nation (MFN) approach for drugs administered by providers in Medicare and rebate reform for the Medicare Part D program. Both rules represent fundamental shifts in our current system and have significant implications for manufacturers, health plans, pharmacies, providers, and patients.

Video: 2020 Election with Avalere: What Are the Drug Pricing Policies?

Tune into our third episode of the Avalere Health Essential Voice: 2020 Election series. In this segment, our experts discuss candidates’ respective approaches to drug pricing policies, and where there is unexpected overlap.

Podcast: 2020 Election with Avalere: What Are the Drug Pricing Policies?

Tune into our third episode of the Avalere Health Essential Voice: 2020 Election series. In this segment, our experts discuss candidates’ respective approaches to drug pricing policies and where there is unexpected overlap.

“Most Favored Nation” EO Creates New Questions on International Prices

On September 13, the Trump Administration released the much-anticipated “Most Favored Nation” (MFN) Executive Order (EO), calling for models that would cap the price Medicare pays for select Part B and D drugs. The President’s EO underscores the administration’s continued focus on reducing prescription drug price disparities between the US and other developed countries.

EOs Direct Drug Pricing Action, Raise Additional Questions

The administration’s 4 drug pricing EOs direct agency action across a host of policy areas, including Part D rebates, Part B reimbursement and pricing, 340B drug discounts, and drug importation. Next steps and a timeline for agency action will vary by EO dependent on the specific policies to be advanced or finalized. In the interim, stakeholders should explore outstanding questions and contemplate near- and longer-term policy scenarios.

Avalere Statement on Prescription Drug Pricing Executive Orders

On July 24, the administration released 3 executive orders (EO) and announced the planned publication of a fourth EO, all focused on prescription drug pricing. The EOs reflect a combination of familiar policy goals (e.g., rebate reform, importation, international pricing) and a new 340B initiative, and in combination could have substantial implications for healthcare stakeholders and pharmaceutical markets if implemented.

Podcast: E4 – Specialty Pharmacy Stakeholder Perspectives: COVID-19 Business Impacts

In the fourth episode of the Specialty Pharmacy Stakeholder Perspectives podcast series, Avalere is joined by Adam Hanauer, Associate Vice President at Humana Specialty Pharmacy, and Mark Sasala, Principal Business Analyst of Products at Creehan & Company, to discuss the outlook of specialty pharmacy with a focus on the environmental considerations and potential impacts of COVID-19.

Follow the Pill: Understanding the Prescription Drug Supply Chain

Prescription drugs are dispensed to patients through a complex supply chain that involves a broad array of entities, contract arrangements, and payments. The following diagram outlines how a typical prescription drug may flow through the drug supply chain.

Kayla Amodeo

Podcast: E2 – Specialty Pharmacy Stakeholder Perspectives: Patient Outlook

In the second episode of the Specialty Pharmacy Stakeholder Perspectives series, Avalere is joined by Marc Boutin, CEO of the National Health Council, discussing the specialty pharmacy dynamics with a focus on the patient perspective.

Podcast: E1 – Specialty Pharmacy Stakeholder Perspectives: Specialty Pharmacy Outlook

In the first episode of the Specialty Pharmacy Stakeholder Perspectives series, Avalere is joined by Joel Wright, CEO at AllianceRx and Ernie Shopes, SVP Products and Client Delivery at Creehan and Company, discussing the outlook for specialty pharmacy, including a focus on trends in the pipeline and overall landscape.

What’s Next for Medicaid Drug Pricing?

On February 27, Avalere experts discussed the latest policy, pricing, and reimbursement challenges for prescription drugs in Medicaid in the “What’s Next for Medicaid Drug Pricing?” webinar. They reviewed the ways prescription drugs are managed in Medicaid, what innovative medicines may mean for the program, and potential implications of CMS’ Healthy Adult Opportunity (HAO).

Podcast: E2 – Avalere Insights on Recent CMS Proposed Payment Rules: MPFS

Tune in to hear the second episode in our 3-part series that focuses on CMS’s most recent proposed payment rules. In episode 2, we’ll be focusing on the Medicare Physician Fee Schedule proposed rule, or MPFS, with a focus on proposed changes to E/M and Opioid Use Disorder (OUD) treatment services.

Podcast: E1 – Avalere Insights on Recent CMS Proposed Payment Rules: OPPS

Tune in to hear the first episode in our 3-part series that focuses on CMS’s most recent proposed payment rules. In episode 1, we’ll be focusing on the outpatient prospective payment system proposed rule, more informally known as the OPPS.

Over Half of Medicare Advantage Beneficiaries Enrolled in Plans that Require Step Therapy for New Starts of Part B RA Biologics in 2019

Avalere analysis of 1,375 Medicare Advantage plans’ 2019 medical benefit drug coverage policies finds that 672—covering approximately 14.3 million lives—apply step therapy to at least 1 of the rheumatoid arthritis biologic drugs covered under Medicare Part B in 2019.

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