California lawmaker aims to reduce drug costs, rein in PBMs with 2 new bills

By Allison Bell - A state legislator in California is bringing back efforts to rein in pharmacy benefit managers and cut prescription costs for insured residents with diabetes. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. PBM Regulation Bill: State Sen. Scott Wiener introduced a bill that would require pharmacy benefit managers (PBMs) to be licensed by the California Department of Insurance, pass all negotiated rebates to payers or patients, and prohibit PBMs from steering patients to their own pharmacies. The California Pharmacists Association is one of the bill's sponsors.

2. Insulin Price Cap Bill: Wiener also introduced a bill to cap out-of-pocket insulin costs at $35 per month for those with commercial health insurance and health maintenance organization coverage, extending cost protections beyond the federal law, which applies only to Medicare enrollees. The American Diabetes Association supports this bill.

3. Governor Newsom's Veto History: Governor Gavin Newsom previously vetoed similar bills in 2023 and 2024, citing the need for more detailed data on pharmacy delivery systems and cost drivers before imposing broad PBM regulations. He also highlighted California's partnership with Civica Rx to produce a more affordable insulin alternative.

Feds rescind proposed rule requiring contraception access

By Noah Tong - A multitude of federal agencies quietly ditched a proposed regulation aimed at expanding access to contraception through health plans, boosting insurers' ability to claim religious or moral objection. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Withdrawal of Proposed Rule: The Department of Health and Human Services, Treasury, and Labor announced the withdrawal of a proposed rule on Dec. 23 after receiving nearly 45,000 public comments, citing the need to focus resources on other priorities.

2. Proposed Changes Under ACA: The proposed rule aimed to modify the Affordable Care Act's preventive services requirements by removing the moral exemption for contraception coverage and introducing an individual contraceptive arrangement to ensure coverage even for members enrolled in plans with religious objections.

3. Historical Context and Policy Shifts: The Trump administration in 2018 expanded both moral and religious exemptions, allowing organizations and educational institutions to opt out of contraceptive coverage, which left some workers without coverage options. The withdrawn Biden administration proposal sought to reverse aspects of this policy.

Payers’ 2025 predictions

By Caroline Catherman - There were a lot of healthcare surprises this year, and there are bound to be at least some in 2025 that take us by surprise. But that won’t stop us—or payers—from trying our darndest to plan ahead! Read Full Article…

HVBA Article Summary

1. Rising Prescription Drug Costs: Prescription drug spending, particularly on high-cost brand medications like GLP-1s for diabetes and weight loss, is expected to continue increasing in 2025. Blue Cross Blue Shield of Massachusetts projects a 250% rise in spending, reaching nearly $200 million in 2024 alone, driven by demand for these medications despite their health benefits.

2. Medicare Advantage Adjustments: Medicare Advantage plans will face financial pressures due to risk adjustment changes, increasing utilization, and stricter star ratings cut points. These factors could reduce plan margins, limit supplemental benefits, and affect enrollment dynamics. Narrow, performance-driven networks may emerge as a strategy to manage costs more effectively.

3. Emerging Specialty Drugs and PBM Role: A new generation of transformative specialty drugs with near-curative effects is set to enter the market in 2025. These complex medications require precise administration and specialized care management. Pharmacy Benefit Managers (PBMs) are expected to play a growing role in ensuring patient access and affordability for these costly treatments.

3 Healthcare Trends to Watch in 2025, Per Red Cell Partners

By Katie Adams - As we enter another new year, healthcare leaders are closely watching trends that are poised to reshape the industry. Leaders from Red Cell Partners — a McLean, Virginia-based investment and incubation firm that funds, builds, and scales startups in the healthcare and national security industries — shared some trends they are keeping their eyes on this year with MedCity News. Read Full Article… 

HVBA Article Summary

1. Medicaid Structural Changes and Impact: In 2025, Medicaid will undergo major structural shifts, including federal cost-sharing caps, block grants, work requirements, and reduced eligibility flexibility. These changes are expected to reduce covered services and increase the number of uninsured individuals, while also presenting innovation opportunities for stakeholders such as startups, regulators, health plans, and state governments.

2. AI Agent Adoption in Healthcare: The adoption of AI agents will expand across the healthcare sector, streamlining administrative tasks, enhancing clinical decision support, and improving patient engagement. Companies like Suki, Kairo Health, and Owkin are already leading in this space, leveraging AI to replace outdated, inefficient processes and legacy technology.

3. GLP-1 Management Frameworks for Employers: Employers will continue refining their GLP-1 medication management strategies, with larger organizations focusing on utilization management techniques. Increased collaboration between employers, pharmacy benefit managers, and third-party vendors could lead to standardized frameworks tailored to employee health demographics and regional healthcare dynamics.

Use of diabetes and anti-obesity drugs surges nationwide

By Tina Reed - The number of prescriptions for GLP-1 drugs jumped roughly 10% in 2024, according to insurance claims data provided to Axios by health analytics company PurpleLab. Read Full Article…

HVBA Article Summary

1. Rising Demand Across States: Data reveals double-digit growth in GLP-1 prescriptions in 23 states, with Rhode Island (67.8%), Massachusetts (48%), and New Jersey (35.8%) experiencing the highest year-over-year increases, while six states, including Arkansas and Louisiana, saw declines.

2. Demographic Insights: Adults aged 55-65 represented the largest group receiving prescriptions (29%), followed closely by seniors 65 and older (26%). The majority of prescriptions were for commercially insured patients, with only 9% covered by Medicaid and 17% by Medicare.

3. Key Medications and Usage Ambiguity: The data covers claims for Novo Nordisk’s Ozempic and Wegovy, along with Eli Lilly’s Mounjaro and Zepbound, but does not distinguish between prescriptions for obesity, diabetes, or heart disease treatment.

Expert: Cybersecurity regulation under Trump a question mark for now

By Ron Southwick - With the top U.S. cybersecurity official making her exit and the incoming administration’s next move anyone’s guess, one legal expert is urging cyber insurance policyholders to ensure their coverage is secure now. Read Full Article…

HVBA Article Summary

1. Potential Regulatory Shift: Arthur Armstrong suggests that cybersecurity regulations could loosen under a Trump administration, given the traditional Republican stance on minimizing regulation while emphasizing national security.

2. Cyber Insurance Market Challenges: Armstrong predicts that obtaining cyber insurance may become more difficult due to market conditions rather than political changes, with stricter requirements such as mandatory multi-factor authentication (MFA) and comprehensive cybersecurity programs.

3. Proactive Risk Management: Armstrong advises businesses to reassess their cyber coverage and risk management strategies now, emphasizing the importance of working with knowledgeable brokers and coverage counsel to prepare for evolving market conditions and potential regulatory shifts.

The 2025 BenefitsPRO health benefits predictions almanac

By Allison Bell - The pages of the old calendar are running out, and employers and their benefits advisors are seeking clues about what 2025 might be like in spreadsheets, AIs and Magic 8 Balls. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Economic and Insurance Market Trends: The global and U.S. economies are projected to experience slower growth and reduced inflation rates in 2025 compared to 2024, with global GDP expected to rise by 2.8% and U.S. GDP by 1.9%. Insurance premium growth is also forecasted to slow, reflecting broader economic trends and wage patterns that could influence health benefits strategies.

2. Health Insurance and Expenditures: U.S. health insurance enrollment is expected to remain stable with minor changes in coverage rates, while health expenditures continue to rise. The total health spending is projected to reach $5.3 trillion, with increased out-of-pocket costs for patients and higher employer-sponsored health insurance spending, emphasizing cost management challenges for both individuals and employers.

3. Trends in Health Benefits Access and Market Shifts: Employer health benefits strategies are evolving, with greater scrutiny on formularies, increased direct contracting with healthcare providers, and the rise of individual coverage health reimbursement arrangements (ICHRAs). Additionally, the health insurance mergers and acquisitions market is shifting, with fewer deals but higher total transaction values, reflecting strategic consolidations in the sector.