Drug Pricing & Pharmacy
Expert articles and analysis related to drug pricing & pharmacy.
AI Summary — Last 30 Days
CMS drug-pricing activity is shifting from one-off negotiation toward model-based Medicaid affordability and utilization management: Indiana Medicaid’s participation in the federal BALANCE Model to cover GLP-1 obesity drugs signals growing willingness to pair access expansion with structured payment controls, while CMS’s proposed drug prior-authorization changes point to tighter federal oversight of pharmacy benefit management in Medicare and Medicaid. The Trump administration is also broadening Medicaid-focused low-price agreements with manufacturers beyond large pharma, creating new rebate and formulary dynamics that VBC organizations will need to track as medication adherence, obesity management, and cardiometabolic risk become larger drivers of total cost of care. For ACOs, MA plans, and Medicaid managed care organizations, the strategic tension is increasingly between expanded access to high-cost therapies and tighter accountability for pharmacy spend, outcomes, and inappropriate payments—reinforced by OIG findings on $587.7 million in ineligible Part D pharmacy payments and emerging models such as Indiana’s GLP-1 coverage through BALANCE and Medicaid low-price drug deals.
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