The thing about being a fiduciary is that all responsibility and liability rests on the plan sponsor. You can hire some pretty awful vendors to manage components of your health plan but mismanagement, excess fees, self-dealing, and profiteering are the plan sponsors peril.  

It’s like the flood gates have opened and all at once what a few of us have been screaming about for years is all of a sudden coming into sharp focus. The class action lawsuits are here and this is a Big One.

“The job of the PBM is to reduce drug costs. Instead they frequency do the opposite.”
Knowing how your PBM makes money is likely the most important component to optimizing your health plan’s Rx spend.

Simpara is announcing that four of their esteemed clients will be honored by Health Rosetta Institute for providing employees one of “America’s Top 50 Health Plans.”

Our Humira-Watch continues as a flood of biosimilars hit the market. Some of these drug options cost 85% less than Humira.

While Americans are enjoying the long holiday break the first interchangeable Rx for Humira quietly launched July 1, 2023 - this means the pharmacy can dispense Cyltezo, the cheaper biosimilar, without a new script.

In a quiet announcement last week, CMS issued a new set of FAQs related to Gag Clause Prohibitions  – a provision included in the Consolidated Appropriations Act of 2021.

Amjevita, the first biosimilar competitor to Humira hit the U.S. market at the end of January.  Showcasing the dysfunction of our healthcare delivery system, the copycat drug came to market with two drastically different list prices. One, a mere 5% discount relative to Humira and another with a 55% discount. Why two prices and who would pay for the more expensive option?  

The Department of Labor gave employers an early Christmas gift last week by issuing a new set of FAQs related to the Consolidated Appropriations Act (CAA) and specifically the new health plan reporting requirements.

We’re hearing rumors from industry insiders that the OMB is set to issue regulations which aim to fix the so-called ACA “Family Glitch” as soon as this coming week. The new rules could take effect as early as November 1, 2022 - just in time for Open Enrollment 2023.

For middle-aged men, 1 in 4 suffers from Obstructive Sleep Apnea (17% for women). The average cost for an in-lab sleep study, used to determine and diagnose sleep apnea is $5,384. A high price tag for a diagnosis which may turn up negative.

In 2003, a little drug named Humira hit the market under the name DE27. Analysts believed at the time that Humira, which was approved to treat Rheumatoid Arthritis, would eventually generate between $500M and $1B in sales annually. In 2021, Humira’s global sales totaled $20.7B. Lifetime earnings have eclipsed $200B.

Last week, the Supreme Court made their decision in Marietta Memorial Hospital Employee Health Benefit Plan v. DaVita Inc., resulting in a 7-2 vote against the major dialysis provider.

We were recently asked what Benefits Reimagined means to us…

Benefits Reimagined means that someone uninsured can get their insulin delivered overnight for free. It means an expecting mother can deliver their child and not worry about affording their deductible because there isn’t one to pay. It means that a woman battling cancer can get the clinical care she needs without having to fight the insurance system that is working against her.

The Supreme Court on Thursday blocked the Biden administration from enforcing a vaccine-or-testing mandate for large employers, dealing a blow to a key element of the White House’s plan to address the pandemic as cases resulting from the Omicron variant are on the rise. But the court allowed a more modest mandate requiring health care workers at facilities receiving federal money to be vaccinated.

Friday, December 17th the 6th Circuit Court of Appeals lifted a stay on the Biden administration rule - requiring workers at companies with 100 or more employees to be vaccinated against Covid or undergo weekly testing.