Nomi Health’s Post

Did you know that more than 75% of Americans don't know that prescription prices vary wildly from one pharmacy to another one? The exact same medication can cost you $10 at one pharmacy and more than $180 at the pharmacy across the street. IntelligentRx provides a powerful search tool to make sure you always pay for the lowest price on your prescription medications and the best part is that it is 100% FREE. #prescriptions #pharmacy #healthcare #medication #rx #affordabledrugs #affordablemeds #genericdrugs #insurance

NABIP: Reps. Cathy McMorris Rodgers (R-WA), Frank Pallone (D-NJ), John Smith (R-MO), and Virginia Foxx (R-NC) introduced H.R. 5378 - the Lower Costs, More Transparency Act - in September. The House is expected to consider the legislation on the evening of Monday, December 11. Please urge your Congressperson to vote in favor of H.R. 5378! The Lower Costs, More Transparency Act (H.R. 5378) is aimed at increasing transparency in healthcare. This legislation addresses key issues like site-neutral payment reforms and more stringent reporting requirements for hospitals and pharmacy benefit managers, aligning with the goal of making healthcare more accessible and affordable for all. More specifically, the legislation: Site-Neutral Payment Reform: Addresses the discrepancy in charges for the same care at different facilities. Enacts a policy for Medicare to have consistent rates for physician-administered drugs across various locations. Hospital Price Transparency: Mandates hospitals to publish an annual list of shoppable services with pricing. From 2026, prohibits the use of internet-based price estimator tools for this purpose. Establishes civil penalties for non-compliance (noting current low compliance rate). PBM (Pharmacy Benefit Manager) Practices: Introduces requirements for PBMs to provide detailed data on prescription drugs to employers. Aims to increase transparency in rebate information, acquisition costs, and formulary placement. Prohibits spread pricing in Medicaid and bars Medicaid MCOs from contracts with PBMs using spread pricing. Contact your Representatives. Take action today! Please urge your Congressperson to vote in favor of H.R. 5378!

When does “catastrophic coverage” kick in with Medicare Part D coverage? There are several stages of Part D prescription drug plans. Below is a high-level outline of the various stages of Part D plans: Stage 1 – Deductible (not all Part D plans have deductibles) Stage 2 – Initial Coverage Stage 3 – Coverage Gap is also known as the Donut Hole Stage 4 – Catastrophic Coverage Starting January 1, 2024, once your out-of-pocket spending reaches $8,000 (including certain payments made by other people or entities, including Medicare’s Extra Help program, on your behalf), you’ll automatically get “catastrophic coverage.” This means you won’t have to pay a copayment or coinsurance for covered Part D drugs for the rest of the calendar year. Contact Marc Robertson at Robertson Insurance contracted with Bridlewood Insurance for all your Medicare needs in San Diego, CA. His no cost expertise is just a call away.

Just when you thought you had seen everything it gets worse. Think about this situation and try to wrap your head around it. Payers (like UHC and Elevance/Anthem) are requiring Rheumatologist and other specialist to use certain biosimilar drugs to treat their patients. No that's the not insanity part. As much as having a payer decide what drug a patient gets is crazy this gets much worse. For some of those drugs the amount the carrier will pay the doctor for that drug is less than what the doctor had to pay to buy the drug. Let me say that again, the carrier makes you use a certain drug then pays you less than the cost of the drug. Yes, you got that right. So let me get this right. These huge, very profitable, insurance companies feel like they can tell doctors what drug to use and then make them provide that drug at below cost? Yup, that seems logical, said no one ever! https://lnkd.in/euughH4P

CMS and HHS dropped an appeal, restoring the 2020 Accumulator Rule, which lets insurance plans exclude only manufacturer assistance from certain prescription drug cost calculations, impacting pharmacies and patient affordability. CMS and HHS plan new rules, reducing short-term risks for Accumulator Adjustment Programs. Read more in our recent alert: https://lnkd.in/giFg3iT9 #specialtypharmacy #healthcare #reimbursement Authors: Jeff Davis, Michael Hess, Whitney Mosey and Shannon Wiley

Prescription Drug spend getting out of hand? Notice how the large recognizable insurance companies who self-fund plans under 500 employees, won’t allow their PBM to be carved out? We have been working with a prospect who is self-funded with one of them. Rx spend is high due to a few members on specialty meds. Nothing being done to manage the cost of these medications currently, so we dove in. We will save them a minimum of 25K on these medications by actively managing these costs. 25K in savings before we even begin to implement cost saving strategies on medical claims. This is what an independent consultant/ TPA is capable of when there are not any misaligned incentives. Let us help you find a solution. Benefit Administration Services, Ltd.

Here's an actual message to an actual patient about their insurance company refusing to pay for cyproheptadine: ====================================================== "Greetings, XYZ, True to form, your insurance company is playing shenanigans again. This time they're asking us to spend time completing an unnecessary form for Cyproheptadine. This particular medication has been around for decades; we use it for itching and as an appetite stimulator. Almost every pharmacy on www.Good Rx.com has it priced at 15 dollars or less. Thus, I have absolutely no understanding of why your insurance won't cover it (especially since y'all are paying the health insurance premiums every month.) In any case, they denied covering it so you have two options: 1) Call them and yell at them. I sent the forms to you so you have all the ammunition you need. Keep in mind that no, they don't need medical records and that I wouldn't recommend you send them because you'd be letting sensitive information out of our control.  2) Just buy the medication directly from one of the pharmacies on www.Good Rx.com or even www.CostPlus Drugs. com In both situations, you can contact the pharmacy and have them transfer it from CVS (though CVS looks like they have it for about 14 dollars.) I'm sorry your insurance is putting up barriers to your care. I find that publicly shaming your health insurance company is helpful as well (especially on Twitter or Facebook.) Hope your holiday season is otherwise good! ===================================================== 2024 is the year that I empower patients to fight their insurances to pay them back. Y'all pay these jokers hundreds/thousands of dollars every month and they keep it. Make them feel your frustration and anger. #priorauthorization #healthinsurance

Yesterday the WSJ published a telling article I encourage all employers & plan sponsors to read. It is no secret Pharmacy costs are out of control - representing the fastest growing component of an employers' health insurance program. But why? Specialty drugs and market consolidation are common answers, however there's more behind the curtain. Looking deeper into how #genericdrugs are sourced by insurers and PBMs, you will find insurance plans can be charged 3 - 100x the generic's fair market price. This is why organizations like Mark Cuban's costplusdrugs.com are exploding! (Please read the article for examples) While the employee might just be on the hook for a copay, what happens to their premiums next year? What happens to the quality of their plan? If you are curious how plan sponsors can fight back against inflated Rx spend, our #CBIZ Pharmacy Consulting Practice has some ideas. https://lnkd.in/gCJuhpHM

This study is a must read for those interested in Rx pricing. "Commercial insurance beneficiaries paid the entire PBM-set price 59% [!!!] of the time (5.9 million of 10 million claims), while Part D beneficiaries were impacted to a lesser degree at 25% (4.3 million of 17 million claims). ... At first glance, Figure 36 may help explain the growth of GoodRx, SingleCare, and other cashbased pharmacy programs (such as Freedom Pharmacy and the Mark Cuban Mark Cuban Cost Plus Drug Company, PBC over the last several years. (52) If the majority of patients have prescription drug benefits through their employer, and the majority of those individuals (based on Figure 36) are paying full drug prices without financial support from their health insurer and PBM, and many drug prices can be exceedingly high through insurance relative to the underlying drug’s costs, then we can better understand why there is a growing demand for solutions targeted at lowering costs at the pharmacy counter for patients." h/t to Health Tech Nerds for including the study in the weekly newsletter. So much good data here. PS - this chart is why GoodRx's recent integration w/ ESI & Caremark led by Cynthia Meiners is so innovative