Proposed CMS rule would set prior auth deadlines for drugs

By Paige Minemyer – The Trump administration has issued a proposed rule that aims to significantly overhaul prior authorization for pharmaceuticals. Through the Interoperability Standards and Prior Authorization for Drugs rule, the Centers for Medicare & Medicaid Services said it would establish deadlines for payers in government insurance plans, setting the timeline at 24 hours for urgent requests and 72 hours for standard determinations. In addition, the rule would require insurers to publicly report certain metrics around prior authorization, including approval and denial rates, appeal outcomes and decision timeframes, according to an announcement from the agency. Read Full Article...

HVBA Article Summary

1. Establishment of Standardized Prior Authorization Timelines: The proposed CMS rule introduces strict deadlines for insurers to respond to prior authorization requests for pharmaceuticals, aiming to reduce delays in patient access to medications. Urgent requests must be addressed within 24 hours, while standard requests have a 72-hour window. This move is intended to ensure that patients receive timely decisions regarding their prescriptions, potentially improving health outcomes.

2. Increased Transparency and Reporting Requirements: Insurers would be required to publicly disclose key metrics related to prior authorization, such as approval and denial rates, appeal outcomes, and decision timeframes. By mandating this level of transparency, the rule seeks to hold payers accountable and provide patients and providers with clearer information about the prior authorization process. This could also facilitate oversight and identify areas where further improvements are needed.

3. Push for Electronic and Interoperable Systems: The rule emphasizes the adoption of electronic prior authorization processes, including the use of APIs and FHIR-based standards, to replace outdated and fragmented systems. By modernizing these workflows, CMS aims to streamline the process for providers and reduce administrative burdens. The agency is also soliciting feedback on additional reforms, such as improving care coordination notifications and enhancing cybersecurity for insurer systems.

Stop-loss insurers are using new tools to 'laser' out more patients

By Allison Bell – New predictive claim modeling tools could be making real changes in how employers, stop loss insurance providers and benefits advisors think about high-risk employer plan participants. John Thornton, an executive vice president at Amalgamated Life, a company that's been offering medical stop-loss insurance since 2008, said in an email that he thinks the tools are adding to stop-loss insurers' use of "lasering," or excluding coverage for claims associated with certain participants. "With the frequency of claims in excess of $1 million rising significantly, carriers are using lasers more frequently to mitigate risks," Thornton said. One reason is pressure to hold down stop-loss claim costs, but another is because of improvements in data technology, Thornton said. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Data Technology Enhances Risk Assessment: Improvements in data technology are making it easier for health plans and insurers to collect and share detailed claims information. Stop-loss carriers are increasingly requesting this data to better predict the likelihood and cost of high-value claims. Employers are adapting by seeking more competitive stop-loss policy structures, including options without new lasers.

2. Data Transparency Impacts Underwriting Decisions: The same data used by employers to identify wellness opportunities is also helping insurers pinpoint individuals who may incur over $1 million in healthcare costs. This increased visibility enables more precise underwriting and risk selection by stop-loss issuers. As a result, the balance between managing risk and maintaining fair coverage terms is becoming more complex.

3. Market Pressures Drive Strategic Shifts: The stop-loss market is facing ongoing financial pressure, with some insurers exiting while others focus on disciplined growth and underwriting practices. Although claims trends have stabilized at a high level, profitability challenges persist for certain carriers. Despite these dynamics, many employers continue to favor self-funded plans with stop-loss coverage due to greater flexibility and access to detailed claims data.

Healthcare AI market heats up

By Naomi Diaz – It took less than a week at the start of 2026 for three of the world’s largest technology companies to each announce dedicated health AI products. The rush has not slowed since. OpenAI, Anthropic and Amazon all debuted consumer and enterprise health AI tools in January. Microsoft followed in March. Epic Systems unveiled a sweeping new AI roadmap at the annual Healthcare Information and Management Systems Society conference in Las Vegas. Read Full Article...

HVBA Article Summary

1. Major Tech Companies Enter Health AI Market: In early 2026, leading technology firms including OpenAI, Anthropic, Amazon, Microsoft, Epic Systems, and Oracle Health launched or expanded dedicated health AI products. These offerings range from consumer-facing tools to enterprise solutions for clinicians and administrators. The rapid succession of announcements signals a significant shift in the healthcare technology landscape.

2. Diverse Applications and Compliance Focus: The new AI tools address a wide array of healthcare needs, such as personalized health guidance, clinical documentation, patient communication, and regulatory submissions. Many of these products emphasize compliance with healthcare regulations like HIPAA and integrate with existing health records and provider networks. This approach aims to ensure both utility and data privacy for users and institutions.

3. Growing Adoption and Industry Impact: Adoption of these AI solutions is already widespread, with millions of Americans reportedly using tools like ChatGPT for health-related questions daily. Health systems and hospitals are early adopters, leveraging AI to streamline workflows and improve patient care. The convergence of tech giants in this space is drawing comparisons to previous technology platform shifts, suggesting that AI could rapidly reshape healthcare delivery and operations.

AHA names its preferred cybersecurity provider

By Susan Morse – The American Hospital Association has named Rubrik as a Preferred Cybersecurity Provider. Rubrik, a security and AI operations company, offers cyber resilience and data protection tools, ransomware training and financial risk analysis to nearly 5,000 AHA member hospitals. These member hospitals will have access to a breach recovery playbook to keep care running, according to Rubrik, which said it is shifting the focus from stopping attacks to rapid recovery. "A cyberattack against a hospital, which disrupts or delays healthcare delivery, is more than a technical issue; it is a threat to life crime," said John Riggi, national advisor for cybersecurity and risk at AHA. Read Full Article...

HVBA Article Summary

1. AHA's Partnership with Rubrik: The American Hospital Association has selected Rubrik as its preferred cybersecurity provider, granting nearly 5,000 member hospitals access to specialized cyber resilience resources. This partnership aims to enhance hospitals' ability to recover quickly from cyberattacks, rather than focusing solely on prevention. The collaboration reflects a strategic shift in the healthcare sector's approach to cybersecurity, emphasizing operational continuity during breaches.

2. Comprehensive Cybersecurity Support: Rubrik will provide member hospitals with a breach recovery playbook, ransomware training, and financial risk analysis tools. The company’s Cyber Resilience Bundle includes identity recovery and Microsoft 365 protection, as well as a ransomware-response workshop and a five-year financial impact assessment. These resources are designed to help hospitals maintain critical operations and minimize the impact of cyber incidents.

3. Growing Threats to Healthcare Data: Since 2009, over 935 million healthcare records have been exposed in large breaches, highlighting the persistent vulnerability of the sector. The AHA’s Preferred Cybersecurity & Risk Provider Program, launched in October 2025, identified more than a dozen companies to help protect hospitals and health systems from both cyber and physical threats. The scale of these breaches underscores the importance of robust cybersecurity measures for patient and community safety.

Consumers' satisfaction with health plan apps improves with familiarity: JD Power

By Paige Minemyer – Consumer experiences with insurers' digital platforms improve as they become more familiar with the tools, and supporting uptake offers a significant opportunity for the industry, a new survey shows. JD Power releasedits annual study examining customers' attitudes toward digital channels and found that more than a third (38%) of people enrolled in commercial plans use their insurers' digital app. That marks a notable jump from last year, when 31% were actively using health plan apps. However, usage is on the decline among Medicare Advantage enrollees, the survey found. Read Full Article...

HVBA Article Summary

1. Increased Familiarity Drives Satisfaction: The JD Power survey indicates that as consumers spend more time using their health plan's digital platforms, their satisfaction with these tools rises. This trend is especially pronounced among members who have been with the same plan for several years, suggesting that onboarding and ongoing engagement are key to positive digital experiences. The findings highlight the importance for insurers to invest in member education and outreach to boost familiarity and satisfaction.

2. Divergent Usage Trends Between Plan Types: While commercial plan members are increasingly adopting digital apps, with usage rising from 31% to 38% in one year, Medicare Advantage members are using these apps less frequently. The decline in Medicare Advantage app usage suggests that older populations may face unique barriers or have different preferences regarding digital health tools. Insurers may need to tailor their digital strategies to address the specific needs and challenges of different member groups.

3. Positive Experiences Encourage Continued Use: The study found that a strong majority of commercial and Medicare Advantage members are likely to continue using their health plan's app if they have a positive experience. Conversely, poor experiences significantly reduce the likelihood of continued use, underscoring the impact of user experience on digital engagement. This emphasizes the need for insurers to focus on app usability, content quality, and support to retain and grow their digital user base.

Novo Nordisk’s explosive Wegovy pill launch draws a new wave of patients into GLP-1 weight loss treatment

By Annika Kim Constantino – After years of trying to lose weight “the right way,” Jane Zuckerman realized that “putting in the work just wasn’t enough.” Zuckerman, a 32-year-old data analyst based in Washington, D.C., said she lost 90 pounds in college and spent years cycling through nutritionists, therapy and strict routines — only to find herself at her heaviest after the pandemic, at 270 pounds. Zuckerman said GLP-1 injections were out of the question, because she’s afraid of needles. But when the first GLP-1 pill for obesity became available in early January, Zuckerman called her doctor immediately, she said. Read Full Article...

HVBA Article Summary

1. Wegovy Pill Expands Obesity Treatment Market: The launch of Novo Nordisk’s Wegovy pill has attracted a significant number of new patients who previously avoided GLP-1 treatments due to needle phobia or high costs. Many of these patients had not used branded GLP-1 injections before, indicating the pill is expanding the market rather than simply shifting existing users from injections to pills. This trend suggests oral GLP-1 options may make obesity treatment more accessible to a broader population.

2. Patient Experiences and Side Effects Vary Widely: Early users of the Wegovy pill report a range of experiences, from notable weight loss and reduced appetite to minimal results and gastrointestinal side effects. Some patients have found the pill’s dietary restrictions or side effects challenging, leading them to adjust dosages or consider switching to injections. These varied outcomes highlight the importance of individualized treatment plans and ongoing monitoring by healthcare providers.

3. Pricing and Competition Shape Future Adoption: The Wegovy pill’s relatively low entry price has contributed to its rapid uptake, but its impact on Novo Nordisk’s market share remains uncertain as competition from Eli Lilly’s new oral GLP-1 drug emerges. Analysts project continued growth in the overall Wegovy portfolio, with the pill expected to contribute significantly to future sales. However, questions remain about long-term effectiveness, tolerability at higher doses, and how the pill will perform as more oral options become available.

Amgen's lung cancer drug tarlatamab wins China approval

By Andrew Silver – Amgen's (AMGN.O) lung cancer drug tarlatamab has won approval from China's National Medical Products Administration, ‌its development and commercialisation partner BeOne Medicines said on Friday on WeChat. The drug is a targeted immunotherapy for adults in the extensive-stage of ⁠hard-to-treat small cell lung cancer that has worsened despite chemotherapy. The U.S. drugmaker sells tarlatamab in its home market under the name Imdelltra. It is part of Amgen's pipeline of bispecific antibodies designed to attach to a ‌cancer ⁠cell and an immune cell, bringing them together so that the body's immune system can kill the cancer. Read Full Article...

HVBA Article Summary

1. China Approval Expands Access: Amgen's tarlatamab has received regulatory approval in China for use in adults with extensive-stage small cell lung cancer that has progressed after chemotherapy. This approval could significantly expand access to the drug in one of the world's largest healthcare markets. The move reflects growing international recognition of innovative cancer therapies developed by global pharmaceutical companies.

2. Mechanism and Innovation: Tarlatamab is a targeted immunotherapy classified as a bispecific antibody, which works by binding both cancer cells and immune cells to facilitate the immune system's attack on the tumor. This approach represents a newer generation of cancer treatments that aim to harness the body's own defenses. The drug is already marketed in the United States under the name Imdelltra, highlighting its established presence in other major markets.

3. Commercial Prospects and Uncertainties: Some Wall Street analysts estimate that tarlatamab could generate annual sales exceeding $2 billion for Amgen. However, details regarding the launch date and pricing for the Chinese market have not been disclosed by Amgen or its partner BeOne Medicines. The commercial success of tarlatamab in China will likely depend on market access, reimbursement policies, and competition from other therapies.

At Phillips 66, a benefit leader's cancer diagnosis is a catalyst for change

By Lee Hafner – "You're young, you're healthy, it's nothing to worry about." Benefits adviser Jessica Domann recalls these bits of conversations with her gynecologist, whom she visited in late 2022 at the age of 41 after feeling a lump in her breast, and again right after a radiologist said he was "90% sure" the mass was benign. She sought approval for a biopsy anyway, seeking 100% certainty. Her results would change her world — and how she designed cancer support for her company. Two days after the biopsy, Domann was diagnosed with triple negative invasive ductal carcinoma — the most aggressive form of breast cancer. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Personal Experience Drives Benefits Innovation: Jessica Domann’s cancer diagnosis and treatment journey highlighted gaps in the employee benefits system, even for someone with deep expertise. Her firsthand struggles navigating claims, accommodations, and available resources led her to recognize that other employees likely faced even greater challenges. This realization prompted her to advocate for clearer communication and more accessible support within her organization.

2. Comprehensive Cancer Support Initiatives: In response to her experience, Domann and her team developed a digital Cancer Care Resource Guide to streamline information and resources for cancer patients, survivors, and caregivers. Phillips 66 also expanded its benefits by adding Color Health’s cancer screening and genetic testing to its health plans, making preventive care and support more accessible to nearly 12,000 employees. These changes aimed to address both the logistical and emotional needs of employees dealing with cancer, ensuring support throughout the entire journey.

3. Importance of Humanizing Benefits Communication: Domann emphasizes the need for benefits information to be delivered with empathy and a personal touch, rather than just as policy details. She believes that relatable stories and visible advocates can motivate employees to engage with their benefits and prioritize their health. Her experience underscores the value of a human-centered approach in benefits design, especially for serious health conditions like cancer.