BCBS Mich. Sued AGAIN, NYC Gov Retirees Avoid Medicare Advantage, 2025 Trends in Drug Benefit Design

Hey all,

Happy hump day! I spent yesterday at the Transparency RX conference hearing from transparent PBMs, Senator Bill Cassidy, and Administrator Mehmet Oz (obviously the best speaker). While there are a lot of obstacles to a more transparent prescription drug ecosystem, it became clear that the solutions are here and just need to be adopted. Enjoy the rundown!

Jacob Brody (Co-Founder & CEO, ZorroRX)

(PLANSPONSOR) Blue Cross Blue Shield of Michigan Sued for Alleged ERISA Violations

Wesco Inc. has filed a federal lawsuit accusing Blue Cross Blue Shield of Michigan (BCBSM) of violating ERISA by profiting off self-funded health plans through unauthorized fees tied to a “Shared Savings Program.” The suit claims BCBSM charged up to 30% in fees for correcting its own billing mistakes—practices that may violate fiduciary duties and incentivize error-based profiteering. It’s like a waiter spilling your soup and then charging you a fee for cleaning it up before it stains your shirt. Full Article

(Health Care Un-covered) NYC Retirees Defeat Medicare Advantage Plan

In a major victory for New York City’s 250,000 retired municipal workers, Mayor Eric Adams abruptly ended his administration’s plan to force retirees into a privatized Aetna Medicare Advantage plan. The decision follows years of legal battles and grassroots advocacy led by the NYC Organization of Public Service Retirees, who opposed the move due to Medicare Advantage’s restrictive care networks and pre-authorization hurdles, and signals a broader pushback nationwide against privatizing senior healthcare. Maybe Adams finally realized New York City didn’t need to hand out corporate welfare to CVS/Aetna—Uncle Sam’s already doing a fine job of that. Full Article.

(Pharmaceutical Strategies Group) 2025 Trends in Drug Benefit Design

The 2025 Trends in Drug Benefit Design Report from PSG reveals increasing payer focus on affordability and transparency as drug costs rise, particularly regarding GLP-1 medications and unbundled PBM service models. Nearly all payers cover GLP-1s for diabetes, but less than one-third do so for obesity, with 42% unwilling to cover them at any price, reflecting high cost concerns. Interest in unbundled PBM services is growing, with a third of payers considering the shift for improved transparency and financial control. Employers and health plans are also actively exploring alternative pricing models, cost-sharing adjustments, and the use of weight management vendors to better manage rising drug trends—but instead of just choosing a transparent PBM, many are still handing the keys to the fox guarding the henhouse. Full Article