PBM Transparency Theater Gets Lukewarm Reviews, 33% of Zepbound Customers Skip Insurance, and Investigation InMA Plans Phantom Behavioral Health Networks

Hey all,

Happy hump day! the healthcare system has perfected the art of looking like it's doing something while ensuring nothing fundamentally changes. Cigna's rebate elimination mirrors a 2018 UnitedHealth initiative that quietly fizzled, Eli Lilly's cash prices beat insurance coverage because PBM contracts won't allow employers the same deals, and Medicare Advantage plans maintain ghost provider networks while collecting taxpayer capitation payments. Transparency, competition, and accountability are all wonderful concepts—just not ones we're interested in implementing when the current arrangement works so profitably.

Enjoy the rundown!

Jacob Brody (Co-Founder & CEO, ZorroRX)

(Cost Curve) Cigna Rebate Announcement Analysis

In a sharp breakdown by Brian Reid, Cigna’s plan to pass pharmacy rebates directly to consumers triggered political posturing, historical déjà vu, and market indifference—suggesting its impact may be more symbolic than structural. Reid compares the move to UnitedHealth’s similar 2018 initiative, which fizzled due to its narrow focus on fully-insured plans, leaving the more influential self-insured market untouched. As Cigna’s stock stayed flat and analysts yawned, we’re all left stunned—stunned!—that a major PBM “transparency” announcement might actually be a red herring. Full Article.

(Endpoints News) LillyDirect’s Growing Role in Zepbound Prescriptions

More than a third of new prescriptions for Eli Lilly’s weight-loss drug Zepbound now come through its direct-to-consumer platform, LillyDirect, signaling growing consumer demand for simpler, more direct access to treatment. The discounted self-pay pricing launched in August 2024 wasn’t made possible by existing PBM contracts—in fact, those contracts prevent Lilly from offering the same deal to employer-sponsored plans, even when they ask. Because only in American healthcare could paying cash out-of-pocket save you money vs. using your coverage. Full Article.

(Health Care Un-Covered) Ghost Providers in Medicare and Medicaid

A new report from the Department of Health and Human Services’ Office of Inspector General (OIG) reveals that many Medicare Advantage and Medicaid plans list “ghost providers”—behavioral health professionals who are either inactive or not actually seeing patients—giving the illusion of robust care networks. This widespread inaccuracy means millions of Americans struggle to access mental health care, while insurers continue to collect taxpayer money through pre-paid capitation models that reward cost-cutting over care. The OIG suggests using actual billing data and creating a national provider directory—recommendations that are moving at a bureaucratic crawl while the problem races ahead. Full Article