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.
USPSTF at a Crossroads: Preventive Care Coverage Mandate at SCOTUS
The Supreme Court weighs a case that could reshape access to no-cost preventive services under the ACA and redefine USPSTF's legal authority
Site of Care Optimization Offers Savings for Specialty Services
Across physician specialties, Medicare utilization and reimbursement data shows that site-of-care optimization can reduce expenditures for certain healthcare services.
How a New Technology Add-On Payment (NTAP) Works
Additional Medicare payment in the inpatient setting may be available to certain qualifying new technologies, but requires successful navigation of application processes.
Part D Prior Authorization Policies May Include Step Therapy
Analysis of Part D plans including step therapy in prior authorization and the frequency of step therapy criteria that include steps beyond the drugs’ FDA labels.
Expiration of Enhanced Tax Credits Would Impact 18M Americans
If the ACA marketplace enhanced premium tax credits are made permanent, nearly 5 million people ages 50–64 will be eligible to receive premium subsidies in 2026.
Part D Coverage of MS Drugs Declined in 2025
Overall coverage of MS drugs among Part D plans declined by six percentage points, from 49% of the time across all plans and drugs analyzed in 2024 to 43% in 2025.
Impact of J-Code Naming Conventions on 505(b)(2) Drugs
Manufacturers have noted challenges arising from 505(b)(2) code descriptors, prompting CMS to consider proposed updates
Highlights From The 2024 InformaConnect Congress
Two Avalere experts captured information presented at a recent conference and published their perspectives in Pharmaceutical Commerce.
Health Plans 2030: Unlocking Value through Data & Technology Advancements
With increasingly sophisticated data and technology available, plans should strategize about how to integrate both across the enterprise to drive higher value.
RxHCC Model May Not Accurately Predict Costs for Certain TAs
Avalere analysis finds that the Part D risk adjustment model likely underpredicts expenditures for some high-cost conditions.
Study: 57 Percent of Covered Generic Drugs Not on Part D Generic Tiers in 2025
Over time, the percentage of generic prescription drugs placed on Medicare Part D generic tiers has declined, from 65% in 2016 to 43% in 2025.
2025 Part D Formularies Shift to More Coinsurance and UM
While the share of drugs covered on Part D formularies will increase slightly in 2025, more drugs will have coinsurance and utilization management.
Mental Health Parity Rule: Industry Reactions and Implications
Stakeholders are contending with a new rule implementing stricter requirements on mental health care parity to ensure patient coverage and enhance equity.
Accelerating Access With Access Marketing
Access marketing requires a strategic approach that combines data and storytelling to communicate product value and differentiation and ensure patient access.
SNF 3-Day Waiver Use at the End of the COVID-19 Public Health Emergency
Use of the three-day waiver was stable over the course of the pandemic, though shifts in admission sources were observed.
125,000 in MS Could Gain Medicaid Coverage Through Expansion
If Mississippi expands Medicaid to 138% federal poverty level, Avalere estimates 125,000 uninsured individuals, ages 19-64, could gain coverage in 2025.
CMS Expands Medicare Device Access Via New TCET Pathway
The new Transitional Coverage for Emerging Technologies pathway will provide Medicare coverage for up to five FDA-designated Breakthrough Devices per year.
Formulary Coverage and Access Shifts in 2024 PDPs
Avalere analysis shows that there are substantial changes and variations in PDP formularies at the therapeutic area and regional levels from 2023 to 2024.
More Low-Income Subsidy Enrollees Pay Part D Premiums in 2024
An Avalere analysis finds that from 2023 to 2024 the number of LIS enrollees paying a Part D premium increased by more than 1 million enrollees.
2025 a Unique Year for MA and Part D Plans’ Rebate Reallocation
Given increased plan liability under the IRA and uncertainty from late changes to Star Ratings, plans should strategize for their Rebate Reallocation process.