Aetna, Cigna, UnitedHealth affiliates face PBM suit setback

By Allison Bell – A federal judge in Rhode Island is letting the state of Rhode Island move forward with a suit against the three big pharmacy benefit managers. The state has filed a complaint in the U.S. District Court for the District of Rhode Island that accuses the PBMs of violating the federal Deceptive Trade Practices Act by inflating prescription drug prices, misleading consumers about how they affect drug prices, and using access to better slots on prescription drug plan "formularies," or covered drug lists, to persuade drug manufacturers to use rebate arrangements to pay them more. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Judge Allows Rhode Island PBM Lawsuit to Proceed: Pharmacy benefit managers (PBMs) asked the court to dismiss Rhode Island’s lawsuit, arguing the court lacked jurisdiction and that the state failed to present a plausible claim under the Deceptive Trade Practices Act. U.S. District Judge Melissa DuBose denied the motion, stating that courts must view the plaintiff’s allegations in the light most favorable to the plaintiff at the dismissal stage. The ruling allows the case to continue through the legal process rather than being dismissed early.

2. Allegations Focus on Contractual Practices in Drug Supply Chain: Rhode Island’s complaint alleges that PBMs use complex and opaque contractual relationships with other participants in the prescription drug supply chain to maximize profits. Although the state has not yet presented detailed documentation supporting these claims, the judge determined that the allegations warrant further examination. The court concluded that the issues raised in the case are better evaluated after discovery, when additional information becomes available.

3. Case Involves Major PBMs Amid Broader Industry Litigation: Defendants in the lawsuit include CaremarkPCS Health (a CVS Health subsidiary), Evernorth and Express Scripts (affiliated with Cigna), and OptumRx (affiliated with UnitedHealth Group), along with related affiliates and group purchasing organizations. CVS declined to comment on the case, and other parties did not immediately respond to requests for comment. The lawsuit is part of a broader wave of recent litigation involving PBMs, including cases related to insulin pricing and formulary placement decisions.

Texas Tried to Enforce Basic Network Standards — The Industry Ran to Court to Stop It

By Wendell Potter – Readers of HEALTH CARE un-covered know we focus a lot on the barriers health insurance companies have erected that make it harder for their enrollees to get the care they need, including unnecessary and excessive prior authorization requirements, unaffordable out-of-pocket costs and inadequate provider networks. That third barrier has gotten less attention than the other two, but networks without a sufficient number of clinicians within a reasonable distance of a health plan’s enrollees can be lethal, as ProPublica’s Max Blau reported so poignantly in a story that was dramatized on a New York stage last year. Read Full Article...

HVBA Article Summary

1. Texas Expands Enforcement of Network Adequacy Standards: Texas lawmakers unanimously passed a 2023 law giving the Texas Department of Insurance (TDI) greater authority to enforce health plan network adequacy standards. These standards limit how far patients must travel for care, including 30 miles for primary or general hospital care in urban areas and 75 miles for specialty services, with different limits for rural patients. The law also restricts how often insurers can receive waivers and requires compliance before insurers can enroll patients in their plans.

2. High Rate of Noncompliance and Reduced Waiver Approvals: Prior to the law’s passage, TDI reported that more than 90% of health plan networks in Texas failed to meet statutory adequacy standards. Insurers frequently requested waivers stating they could not meet the requirements, and the department had routinely approved those requests. After the new law took effect, TDI began denying some waiver applications as part of its effort to enforce the updated standards.

3. Insurers Challenge Enforcement as Litigation Moves Forward: The Texas Association of Health Plans filed a lawsuit arguing that some counties lack sufficient specialists and hospitals to meet the requirements. In January, a state court granted temporary injunctive relief that prevents TDI from denying certain waiver requests while the case is pending. The court order also directs the state to pursue additional rulemaking related to the law’s implementation, and a trial is scheduled for October 19, 2026.

ACA premium spike funnels more consumers into high-deductible plans: CMS

By Rebecca Pifer Parduhn – The CMS’ new ACA open enrollment report includes data from people who signed up for coverage or were reenrolled automatically for 2026. It found total enrollment in ACA plans fell by 1.2 million people this year, to 23.1 million enrollees. Market watchers had expected an even steeper enrollment drop after the expiration of enhanced tax credits at the end of 2025 left millions of Americans facing intense sticker shock for ACA coverage. The average ACA out-of-pocket premium jumped from $113 a month in 2025 to $178 a month in 2026, according to the new federal data. Read Full Article...

HVBA Article Summary

1. Premium Increase Lower Than Earlier Projections: Initial projections from health policy research group KFF estimated that ACA premiums could rise by about 114% if consumers stayed in the same plans. In practice, many consumers switched to plans with lower premiums, reducing the overall increase they experienced. This shift indicates that consumer plan selection played a significant role in moderating the real-world impact of premium changes.

2. Shift Toward Lower-Premium, High-Deductible Bronze Plans: Enrollment in bronze ACA plans increased from 30% of enrollees in 2025 to 40% in 2026. These plans typically have deductibles averaging more than $7,000 per person, resulting in higher out-of-pocket costs for many consumers. Some experts warn that higher deductibles may lead individuals to delay care or face greater risk of medical debt.

3. Enrollment Uncertainty and Expanded Eligibility Checks: Overall ACA sign-ups remain relatively strong compared with levels before 2025, but final enrollment numbers may decline as the year progresses. Some individuals who initially enroll may later drop coverage if they do not pay their premiums, particularly after automatic reenrollment. Additionally, stricter eligibility verification restored by CMS led to about 1.5 million people losing subsidies or coverage due to duplicate enrollment, eligibility issues, or enrollment without consent.

The Top Pharmacy Benefit Managers of 2025: Market Share and Key Industry Developments

By Adam J. Fein, Ph.D. – Three is still the magic number for pharmacy benefit managers (PBMs). For 2025, 80% of all equivalent prescription claims were processed by three companies: the CVS Caremark business of CVS Health, the Express Scripts business of Cigna, and the Optum Rx business of UnitedHealth Group. Express Scripts continued to pull ahead of its peers, while CVS Caremark’s claim volume declined for the second year. Independent PBMs continued to gain business from these larger PBMs, showing fragmentation at the margins. Many smaller PBMs still rely on their larger competitors for claims processing, network management, and rebate negotiation. So even if a plan sponsor chooses an alternative PBM, the Big Three can still win with behind-the scenes economics. Read Full Article...

HVBA Article Summary

1. Market Concentration Remains High: The three largest PBMs—CVS Caremark, Express Scripts, and Optum Rx—continue to process the vast majority of prescription claims in the U.S., maintaining an 80% market share in 2025. This level of dominance has remained stable over recent years, despite ongoing policy debates and competitive pressures. The persistence of this concentration highlights the significant influence these companies hold over the pharmacy benefit landscape.

2. Shifting Competitive Dynamics and Strategic Partnerships: Express Scripts has solidified its lead among PBMs, driven by organic growth, consolidation of large client relationships, and strategic partnerships such as those with Prime Therapeutics and Centene. Meanwhile, CVS Caremark experienced a decline in claims volume, partially due to client transitions, but is expected to rebound with new contracts like CalPERS. The relationships between large and smaller PBMs are complex, with many independents relying on the infrastructure and services of the major players, blurring the lines between competition and collaboration.

3. Industry Evolution and Regulatory Pressures: The PBM sector is undergoing significant changes in response to regulatory scrutiny, client demands, and the emergence of new pricing models such as the Net Pricing Drug Channel. Large PBMs are restructuring their businesses to adapt to these shifts, which affect how they generate profits and negotiate contracts. Additionally, rebate aggregation and group purchasing organizations contribute to double-counting in reported figures, complicating assessments of true market reach and highlighting the intricate economics of the industry.

FDA Approves First Once-Weekly Insulin for Type 2 Diabetes

By Miriam E. Tucker – The FDA has approved the first once-weekly basal analog insulin, Novo Nordisk’s icodec-abae (Awiqli injection 700 units/mL), for adults with type 2 diabetes (T2D). The product is already approved in the EU and 13 other countries, including Canada, Australia, and Japan. In the US, the FDA issued the company a “complete response letter” in July 2024 to its first biologic license application for icodec for use in people with both major diabetes types, in part because of concerns regarding hypoglycemia risk in type 1 diabetes (T1D). In May 2024, an FDA advisory panel voted against its use in T1D while expressing no safety concerns about its use in T2D. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Novo Nordisk Targets Type 2 Diabetes for Weekly Insulin Approval: Novo Nordisk worked with the FDA to focus approval of its once-weekly insulin icodec on patients with type 2 diabetes, where clinical evidence was strongest. Industry experts note that the weekly regimen may simplify treatment for patients who require insulin and are also using once-weekly GLP-1 or dual receptor agonist therapies. The therapy is intended to provide a more convenient dosing schedule compared with daily basal insulin regimens.

2. Phase 3 Trials Demonstrate Comparable or Improved Glucose Control: The approval is supported by data from four phase 3 ONWARDS clinical trials that included 2,680 adults with type 2 diabetes whose blood sugar levels were not adequately controlled with other medications. Across these studies, once-weekly icodec achieved either noninferior or superior glucose-lowering results compared with daily basal insulin when used with mealtime insulin, GLP-1 receptor agonists, or oral medications. Some trials reported numerically higher hypoglycemia rates with icodec, though the differences were not statistically significant.

3. Clinical Use May Require Careful Patient Selection and Monitoring: Some clinicians caution that the long duration of weekly insulin could make dose adjustments more challenging when patients’ activity levels or insulin needs change. Experts emphasize that therapy should be individualized and that patients starting the treatment should receive education about hypoglycemia and ideally use continuous glucose monitoring. Cost and insurance coverage could also affect patient access, as newer diabetes medications sometimes face reimbursement limitations.

The Healthcare Rule CIOs Shouldn’t Overlook

By David Chou – A new federal standard for claims attachments may not make headlines, but it can reduce waste, accelerate payments, and address a major administrative challenge in healthcare. Healthcare leaders have invested in cloud platforms, AI, digital tools, and data upgrades. However, significant inefficiencies persist due to administrative friction. The federal government’s new rule on claims attachments warrants greater attention from healthcare executives. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. New Federal Rule Targets Administrative Inefficiency: The recently introduced federal rule establishes national standards for the electronic exchange of healthcare claim attachments and electronic signatures. This aims to streamline the process by which providers submit additional documentation to payers, reducing delays and manual work. By standardizing these transactions, the rule is expected to minimize administrative friction and improve overall operational efficiency in healthcare organizations.

2. Projected Cost Savings and Operational Benefits: According to government analysis, the long-term financial benefits of the rule are expected to outweigh its implementation costs. Federal estimates suggest a primary net annualized benefit of approximately $303.75 million, with savings stemming from reduced administrative workload, faster claims processing, and fewer errors. These improvements are anticipated to help healthcare organizations modernize their payment workflows and reduce unnecessary expenditures.

3. Implementation Challenges for Smaller Providers: While large health systems are likely equipped to comply with the new standards due to existing enterprise systems, smaller medical groups and physician offices may face greater hurdles. Many of these smaller entities still rely on manual or partially electronic processes and will need to adopt new technology and workflows to meet compliance requirements. The rule’s success will depend on effective implementation across all segments of the healthcare industry, not just on the existence of the regulation itself.

Affordable vs. robust a false tradeoff in health benefits

By Kirat Kharode – Every employer wants the same thing from health benefits: predictable costs and a plan employees can actually use. Yet many organizations end up in a familiar bind — benefits that look affordable on paper but fall apart when people need care or robust plans that feel financially out of reach. This tension between "affordable" and "robust" coverage comes up constantly and can be a real high-wire balancing act for brokers and advisers. But it's often framed the wrong way. The real issue isn't cost vs. generosity. It's how risk is being designed — and where it ultimately lands. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. False Dichotomy Between Affordability and Robustness: The article argues that the perceived tradeoff between affordable and robust health benefits is misleading. Instead of focusing solely on premiums, employers should consider how plan design affects risk distribution and real-world usability for employees. A plan that appears inexpensive may actually shift costs and risks to employees, undermining its value.

2. Hidden Costs of Cost-Shifting: When employers reduce premiums by increasing deductibles, narrowing networks, or adding complexity, they often transfer financial and clinical risk to employees. This can lead to delayed care, increased emergency room visits, and higher long-term costs due to untreated conditions. Ultimately, these hidden costs can outweigh the initial savings and negatively impact employee well-being and organizational productivity.

3. Evaluating Benefits Through Access, Clarity, and Risk Alignment: The article recommends that employers assess health plans based on how quickly employees can access care, how clearly they understand their coverage and costs, and who bears the risk when issues arise. Plans that fail in any of these areas may create downstream problems, even if they seem affordable at first. A resilient benefits strategy prioritizes infrastructure and long-term outcomes over short-term cost reductions.