A look at payers' attitudes toward specialty drug management

By Paige Minemyer – Insurers are putting a growing focus on specialty drugs covered under the medical benefit, and on re-evaluating the efficacy of traditional rebate models, according to a new report. The Pharmaceutical Strategies Group (PSG) on Monday released its annual Trends in Specialty Drug Benefits report, which offers a look at how payers are responding to rising costs for these products and striking a balance between cost management and access. PSG surveyed 228 benefits leaders representing employers, health plans and union coverage, and found that 43% ranked managing specialty drug costs as their top goal. By comparison, 37% said their No. 1 goal is to manage total cost of care, per the report. Read Full Article...

HVBA Article Summary

1. Rising Specialty Drug Volume Drives Management Complexity: Specialty drugs accounted for 76% of new approvals by the Food and Drug Administration last year and about 50% of the current pipeline, underscoring their growing dominance. This surge is making it increasingly difficult for payers to manage therapies across both pharmacy and medical benefits. As a result, more payers identified this cross-benefit complexity as a top challenge than issues like data integration or member affordability.

2. Payers Prioritize Cross-Benefit Formulary Integration: About 68% of payers reported that optimizing specialty formularies across pharmacy and medical benefits is a moderate or major focus. Additionally, 72% already maintain a medical benefit formulary alongside a traditional pharmacy formulary, while 50% of employers and 72% of insurers have cross-benefit formulary strategies underway. These figures highlight a strong industry push toward aligning benefit structures to better manage specialty drug utilization.

3. Cost Pressures Shift Focus Away from Rebates: Approximately 40% of payers said they would accept lower rebates in exchange for stronger utilization management tools to control costs. While 93% of payers receive rebates under pharmacy benefits, only 51% do so under medical benefits, with health plans more likely than employers to access these savings. At the same time, payers are questioning the effectiveness of current pharmacy benefit manager models, even as they continue to expect high service levels and specialized care from specialty pharmacies.

Tennessee Revolts Against Pharmacy Middlemen

By Wendell Potter – The health insurance industry spent years perfecting a playbook for killing state-level reform: threaten economic catastrophe, flood the airwaves with dark money, wrap opposition in the American flag, and dare lawmakers to vote yes anyway. Last week in my home state of Tennessee, the industry’s playbook failed. Republicans and Democrats came together to pass the FAIR Rx Act by overwhelming margins in both chambers: 86-7 in the House, 24-9 in the Senate. Read Full Article...

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1. PBM Divestment Bill Targets Vertical Integration: The proposed legislation would require pharmacy benefit managers (PBMs) to divest from pharmacies they own, directly challenging vertically integrated healthcare companies like CVS Health. These companies often operate as insurer, PBM, and pharmacy simultaneously, which can create financial incentives to favor their own services. The bill is designed to address these structural conflicts rather than mandate pharmacy closures or reduce patient access.

2. National Industry Impact and Market Concentration: The bill has drawn attention from major healthcare firms such as UnitedHealth Group and Cigna, which also use vertically integrated models. Together with CVS, these companies control a significant majority of the PBM market, amplifying the potential impact of similar legislation in other states. Industry reactions suggest concern that this policy approach could spread and reshape the competitive landscape nationwide.

3. Legislative Process Highlights Industry Opposition Tactics: During debate, companies and affiliated groups used strategies such as warning about store closures, funding advertising campaigns, and mobilizing customer outreach to oppose the bill. Supporters argued these efforts were intended to generate public concern rather than address the policy’s core provisions. Despite this, strong bipartisan support for the bill indicates increasing political willingness to regulate PBM practices and address perceived conflicts of interest.

US health insurers advance measures to standardize prior authorization requirements

By Reuters – UnitedHealth (UNH.N), and CVS Health (CVS.N), said on Friday they have standardized data and submission requirements for more than half ​of their prior authorizations, as part of an ‌industry effort to reduce delays and paperwork for patients and doctors. U.S. health insurers, which have come under scrutiny to simplify their requirements ​for prior approval on medicines and medical services, ​have been working to deliver on commitments made last year ⁠to cut red tape and improve transparency. Read Full Article...

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1. UnitedHealthcare Expands Prior Authorization Standardization: UnitedHealthcare, part of UnitedHealth Group, plans to standardize more than 70% of its prior authorization requests by the end of the year. The initiative will apply across its commercial plans as well as government-backed Medicare Advantage and Medicaid businesses. This effort is intended to create a more consistent process for handling authorization requests across different lines of coverage.

2. Industry Adoption of Standardized Processes: CVS Health reported that its Aetna insurance division has already standardized 88% of its prior authorization volume. According to AHIP, the standardized approach will focus on commonly reviewed services such as orthopedic surgeries and imaging procedures like CT scans and MRIs. This reflects a broader industry movement toward simplifying administrative requirements for frequently authorized medical services.

3. Goals and Scope of Administrative Changes: UnitedHealthcare aims to improve predictability, reduce administrative rework, and decrease requests for additional information through standardization. The company also plans to expand the program to more services and reduce the number of procedures requiring prior approval. However, it emphasized that these changes will not affect coverage policies or the clinical criteria used to approve or deny care.

Aetna, Cigna, UnitedHealthcare fined over alleged mental health parity violation

By Alan Goforth – Five major health insurers in Connecticut have been fined for violating mental health parity laws, potentially limiting coverage to mental health care and raising concern that patients may be priced out of seeking treatment. The state Mental Health Parity and Addiction Equity Act requires insurers to submit annual data to the Connecticut Insurance Department, which reviews it to ensure that mental health and substance use disorder benefits are treated the same as medical and surgical benefits. In a recent report, the department cited Aetna, Anthem, ConnectiCare, Cigna and UnitedHealthcare for coverage of mental health treatment that fell short of the coverage they provided for physical illnesses. Read Full Article... ^{_{(Subscription required)}}

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1. Mental Health Parity Report Identifies Ongoing Compliance Gaps: Joshua Hershman stated that regulators will continue using data and enforcement tools to ensure fair access to behavioral health care. The findings highlight the need for continued oversight and corrective action to achieve consistent and equitable coverage. Ongoing monitoring and enforcement efforts are expected to address remaining compliance issues.

2. Disparities in Access and Reimbursement Practices: The report identified unequal reimbursement rates, limited provider networks, and differences in patient access, including longer wait times and lower acceptance of new patients for behavioral health services. These discrepancies indicate that mental health and substance use disorder benefits are not being provided at levels comparable to other medical services. Additional concerns include gaps in documentation and insufficient use of outcome data to monitor and address inequities.

3. State Commitment and Industry Response to Enforcement: Ned Lamont reaffirmed the state’s commitment to strengthening mental health parity laws and ensuring fair, consistent coverage. The Connecticut Association of Health Plans said insurers are reviewing the findings and working toward compliance with regulatory standards. Penalties and further regulatory actions will be determined based on the severity and duration of violations through established enforcement processes.

Employees are ditching benefits for their own health apps

By Jimmy Nesbitt – Most employees are bypassing employer-sponsored programs and benefits and instead building their own ecosystem of digital tools, oftentimes at their own expense, a new survey revealed. Castlight Health's 2026 Employer Health Benefits Experience Survey shows a widening disconnect between the benefits companies offer and what employees actually use. These findings come despite continued significant investment in digital health and well-being programs. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Employee Benefits Awareness and External Spending: Only about one-third of employees clearly understand or regularly use their employer-provided benefits, indicating a gap in awareness and engagement. More than half of employees use consumer health or wellness apps, and 46% pay out of pocket for solutions they find more relevant or easier to use. Annual spending varies, with 61% spending at least $100, nearly one-third exceeding $500, and 15% spending up to $1,500.

2. Demand for Flexible and Personalized Benefits: Employees increasingly value flexibility and personalization in their benefits, with over 80% saying they would be more likely to stay with an employer offering a flexible wellness allowance. Survey insights suggest employees are not asking for more benefits overall, but rather options that better align with their individual needs and lifestyles. Greater choice and control over health-related decisions are emerging as key expectations among the workforce.

3. Differences in Usage Patterns and Engagement Triggers: Benefits usage varies by demographic groups, with younger employees more likely to adopt digital health and wellness tools, while older employees prioritize chronic condition management. Engagement is typically driven by immediate needs such as doctor visits or unexpected health issues, rather than structured events like open enrollment, which only 7% cite as a trigger. These patterns highlight the importance of aligning benefits design with real-life usage behaviors and diverse employee preferences.

CMS, FDA announce new program to speed up Medicare coverage of breakthrough medical devices

By Heather Landi – The Trump administration unveiled a new program to speed up Medicare coverage for breakthrough devices, touting that the new pathway cuts red tape for medical device companies to gain reimbursement. The Centers for Medicare and Medicaid Services (CMS) and the U.S. Food and Drug Administration (FDA) announced on Thursday the Regulatory Alignment for Predictable and Immediate Device (RAPID) coverage pathway for FDA-designated Class II and Class III breakthrough devices. The new pathway creates better alignment between FDA review of medical devices and Medicare coverage decisions, John Brooks, CMS Deputy Director and Chief Policy and Regulatory Officer, and Senior Counselor of the U.S. Department of Health and Human Services, told reporters during a press call Thursday morning. Read Full Article...

HVBA Article Summary

1. RAPID Pathway Accelerates Medicare Coverage for Breakthrough Devices: The RAPID pathway is a new initiative designed to speed up Medicare coverage for certain FDA-designated breakthrough Class II and Class III medical devices. It emphasizes earlier coordination between the Food and Drug Administration and the Centers for Medicare & Medicaid Services to streamline both regulatory review and reimbursement decisions. The program aims to enable Medicare coverage within 60 to 90 days after FDA approval, reducing delays that have historically limited patient access.

2. Early Collaboration Aligns Evidence for Approval and Coverage: The RAPID pathway introduces earlier involvement of CMS during device development, including clinical trial design and evidence generation. This approach is intended to ensure that data collected for FDA approval also meets Medicare coverage requirements, addressing misalignment seen in prior programs like TCET. By coordinating expectations upfront, the program seeks to improve efficiency, reduce duplication, and provide clearer guidance for device manufacturers.

3. Implementation Replaces Prior Programs and Raises Considerations: CMS is pausing the TCET program to focus on implementing the RAPID pathway, reflecting a shift in strategy toward earlier interagency collaboration. While stakeholders view the program as a promising step to improve access to innovative technologies, some note similarities to earlier initiatives with mixed outcomes and stress the importance of effective execution. The pathway highlights ongoing efforts to balance faster access for Medicare beneficiaries with the need for robust evidence and sustainable reimbursement processes.

Use of GLP-1s in Type 1 Diabetes Not Linked to Increased DKA

By Miriam E. Tucker – Off-label use of GLP-1 drugs by people with type 1 diabetes (T1D) did not lead to diabetic ketoacidosis (DKA) or pancreatitis in a large 1-year single-center study. Moreover, GLP-1 agonist use in people with T1D was associated with lower overall rates of hospitalization, as has occurred in type 2 diabetes, endocrinology fellow Justin Do, DO, of Loma Linda University Medical Center, California, reported here at the American Association of Clinical Endocrinology (AACE) Annual Meeting 2026. “I think GLP-1s can help a lot of our patients with T1D, with the cardiovascular benefits, the renal benefits, and a lower hospitalization rate…However, further studies are warranted in this population,” Do told Medscape Medical News. Read Full Article...

HVBA Article Summary

1. GLP-1 Use Expands in Type 1 Diabetes Despite Limited Approval: Off-label use of GLP-1 receptor agonists is increasing among people with Type 1 Diabetes, particularly as obesity rates in this population have risen to about 37% in the United States. Clinicians are exploring these medications for potential cardiovascular and renal benefits, even though they are not FDA-approved for T1D management. At the same time, concerns persist regarding risks such as diabetic ketoacidosis when insulin doses are reduced too aggressively or food intake declines.

2. Study Finds No Increased Safety Signals but Lower Hospitalizations: A retrospective study of more than 7,000 adults with T1D found no significant increase in DKA or pancreatitis among GLP-1 users compared with nonusers. The most commonly used agents included Semaglutide and Tirzepatide, with users generally older and having higher body mass index. Notably, GLP-1 users had a significantly lower overall hospitalization rate, though the study design limits conclusions about causation and underlying reasons.

3. Experts Emphasize Individualized Insulin Management and Need for Trials: Specialists highlight the importance of carefully adjusting insulin doses when initiating GLP-1 therapy to avoid both hypoglycemia and DKA. Early findings and small trials suggest these medications may be safe in T1D, but larger randomized studies are ongoing to confirm efficacy and safety. Until stronger evidence is available, close monitoring and individualized treatment plans remain essential for patients using GLP-1 therapies in this setting.