Coverage and Payment
Coverage and reimbursement shapes patient access and affordability. Life sciences companies rely on favorable coverage decisions to ensure market access and adoption of their products, while health plans need effective reimbursement strategies to manage costs and provide comprehensive benefits to their members.
Medicaid Work Requirements: Understanding Exemptions and Protecting Patients
Medicaid work requirements are expected to start January 2027, with narrower exemptions than anticipated. Learn how life sciences companies, plans, and providers can support patients.
Part B Negotiated Drug Prices: How MA Plans Should Prepare
Part B drugs will be subject to IRA price negotiation for the first time in 2028, introducing new payment uncertainties for Medicare Advantage plans.
Post-Clover and 2027 QBP Re-Calculation: What Could Be Next for MA Stars?
CMS will be re-calculating 2027 QBP ratings following the May 2026 Clover ruling. Avalere Health experts share insights on potential future directions for the MA Star Rating program.
Claim Denials Vary by Specialty in Traditional Medicare
Our analysis of 2023 fee-for-service (Traditional) Medicare claims denials found variations in the percentage and volume across specialty type.
How Can Manufacturers, Payers, Providers, and Patient Groups Prepare for Medicaid Work Requirements?
Stakeholders can prepare for the upcoming implementation of federal Medicaid community engagement requirements, which are planned to go into effect January 1, 2027.
USP’s Draft MMG V10.0: What May Change for Part D Formularies
USP’s draft Medicare Model Guidelines v. 10.0 proposes updates to drug categories and classes that will shape Part D formulary design and patient access for plan years 2028–2030. Public comments are open until June 30.
How can MCOs Prepare for Medicaid Community Engagement (Work) Requirements?
MCOs have an opportunity to prepare for—and mitigate—the impact of Medicaid work requirements, which are expected to go into effect in January 2027.
What to Expect When You’re Expecting (to Submit an ICD-10-CM Code Request)
As NCHS guidance on ICD-10-CM code submissions requests evolve, stakeholders need to be aware of the new parameters to navigate each stage of the proposal with confidence.
Are Cost-Effectiveness Thresholds Fit for US Reimbursement Decision-Making? Methodological, Practical, and Policy Considerations
Cost effectiveness thresholds present conceptual and practical challenges when applied to the US healthcare system.
Bridging the Gap: The Future of GLP-1 Coverage in Part D
The recent delay of the BALANCE Model and the GLP-1 Bridge extension highlight the challenges of expanding GLP-1 access in Part D.
ICD-10 C&M Committee 2026 Spring Meeting: Proposed Code Revisions
On March 17-18, the ICD-10 C&M Committee discussed proposals for 35+ new codes designed to improve accuracy, address emerging health issues, and strengthen disease reporting.
Integrated Clinical and Coding Strategies Drive Market Success
Early, integrated clinical, coding, and reimbursement strategies transform market access challenges into successful launches with clear coverage and payment pathways.
How are States Responding to Medicaid Budget Pressures?
States are taking near-term Medicaid actions in response to funding pressure including changes to benefits, rates, and procurement timelines.
White Paper: Coverage and Utilization Management Trends in the Commercial Market, 2016-2025
For single-source brand drugs across eight TAs, commercial market formulary coverage, in the aggregate, declined by 20 percentage points from 2016–2025
White Paper: FQHC 340B Contract Pharmacies and Medicare HIV Drug Access
Avalere Health found that contract pharmacy relationships do not increase utilization of HIV drugs for Medicare beneficiaries with HIV receiving care at FQHCs.
Coding, Reimbursement, and Clinical Expertise to Support Market Access
Translate clinical innovation into commercial success by tapping into our market access team’s expertise in coding systems and reimbursement policies.
USP DC 2026 Updates and Strategic USP Engagement Opportunities
The updated USP Drug Classification was recently released with several revisions to categories, classes, PGs, and products included. Beyond historical uses, USP’s classifications will be used to inform product eligibility for Medicare MFN demonstrations.
Driving Access to Rare Disease Care via Multi-stakeholder Collaboration: Perspectives from APAC Payers and HTA Experts
This third installment of our APAC rare disease series explores key enablers of achieving higher levels of multi-stakeholder collaboration in funding decisions for rare disease treatments.
Alzheimer’s Fast-Changing Treatment Landscape and Pipeline: Need-to-Know Insights
A robust, diversified clinical development pipeline in AD requires market entrants to establish early differentiation during commercialization planning.
Now Available: 2026-2027 Coverage and Coding Regulatory Calendar
Avalere Health’s new CY 2026–2027 Coding and Regulatory Calendar supports life sciences firms’ strategic planning for critical coding deadlines, timelines, and regulatory updates.