PBM Hit Piece On Critic, Stop-Loss Prices Spike, Small Pharmacies Leave Part-D Networks

Hey all,

Happy hump day! There won’t be a rundown tomorrow as I will be traveling. Enjoy the rundown!

Jacob Brody (Co-Founder & CEO, ZorroRX) 

(Cost Curve) Stelara Biosimilars & PBM Influence

The launch of Stelara biosimilars exposes the flawed incentives in the pharmaceutical market, where lower-cost drugs don’t always gain traction due to rebate-driven pricing structures. Despite new competitors offering drastically different prices, insurers and pharmacy benefit managers (PBMs) continue to prioritize high-list, high-rebate models, often at patients’ expense. Meanwhile, Antonio Ciaccia, a vocal critic of PBMs, is facing what appears to be a coordinated smear campaign, further highlighting the industry’s resistance to transparency. The controversy suggests that PBMs are feeling the pressure from Ciaccia’s data-driven critiques, reinforcing concerns about misaligned incentives in drug pricing. Full Article.

(BenefitsPro) Sun Life Sees Stop-Loss Problems Spiking: Will It Force Employers to Buy Fully Insured Coverage?

Sun Life Financial reported a sharp rise in catastrophic insurance claims in Q4 2024, driven by advanced cancer cases, premature births, and rising hospital costs, prompting a 14% increase in renewal prices and the termination of some high-claim plans. This trend puts pressure on employers with self-insured health plans, potentially forcing them to opt for fully insured coverage, cut benefits, or drop health coverage altogether. While Sun Life believes it has managed pricing better than some competitors, the industry-wide increase in claim severity signals broader challenges. Full Article

(Drug Channels) Why Small Pharmacies Exited Medicare Part D Networks for 2025

Independent pharmacies have largely withdrawn from Medicare Part D’s preferred pharmacy networks for 2025, with major pharmacy services administrative organizations (PSAOs) no longer participating in key plans. This decline reflects broader challenges in the stand-alone prescription drug plan (PDP) market, which has been further destabilized by the Inflation Reduction Act (IRA), reducing premium-free plan options for low-income subsidy (LIS) enrollees. As more beneficiaries migrate to Medicare Advantage prescription drug (MA-PD) plans, small pharmacies face increasing pressure to adapt or risk further marginalization. Full Article