You won’t be surprised when I tell you that my favorite Halloween costume was when I wore a pair of scrubs with vinyl records attached (Spin Doctor). Yep. Right up there with Freudian slips. This year I will stick to my usual costume: the nice lady who hands out full-size bars to 200+ neighborhood kids. It’s the best.
If Not at the Table, On the Menu. On Monday, Cigna’s Evernorth (where Express Scripts lives) said it will end traditional post-sale drug rebates in many commercial plans, shifting to upfront, point-of-sale discounts for fully insured members in 2027. In 2028, they will make this model the default for Express Scripts clients. Essentially, Cigna is potentially getting ahead of pharmacy benefit manager (PBM) reform by trying to set the table. The company touts ~30% average reductions in brand-name costs at the counter, with reimbursement decoupled from list price.
For patients, moving value into the pharmacy lane shrinks the gross-to-net bubble and can improve adherence; for manufacturers, it clarifies how discounts touch patients rather than disappearing into premium offsets. The lever is contract design—coinsurance based on net price, “lowest-of” pricing at the counter, and clean accumulator rules so point-of-sale savings aren’t clawed back elsewhere. The work now is to make sure contract terms match these promises so that patients actually feel the discount.
I Want You to Want Me. On Wednesday, the Food and Drug Administration (FDA) released draft guidance to pare back requirements for approval of most biosimilars in an attempt to speed the time to approval. The FDA is shifting toward advanced analytics instead of human studies, and toward interchangeability.
For manufacturers, that moves investment toward analytics; for patients, it promises faster entry and—if payers follow—earlier access to lower-net options. Comment window first, then final guidance; the near-term lever is substitution policy and payer tiering/interchangeability criteria that determine whether lower net prices actually reach the counter. While good for biosimilar manufacturers, it remains to be seen whether the U.S. market remains viable for them with potential Most Favored Nation drug pricing, Medicare negotiation and tariffs. The practical work ahead for biosimilar manufacturers and patient advocates is to make the science-to-coverage handoff real—ask for clear substitution rules and confirm payers will use them.
More than Words. On Wednesday, the Institute for Clinical and Economic Review (ICER) published its revised Evidence Report on obesity therapies; namely semaglutide (injectable and a not-yet-approved oral) and tirzepatide. Results look strong, and the heart-health evidence is getting clearer. The health benefit benchmark price is between $9,100 and $12,500 for injectable semaglutide, $8,300 and $11,400 for oral semaglutide, and $11,500 and $15,800 for tirzepatide.
And yet. As much as we say we want to pay based on value, access remains limited. The cash price is ~$500/month and payers don’t want to cover it. Which on one hand makes a ton of sense – a lot of people could qualify for coverage, and they are on it for potentially years. But isn’t this exactly what we should be trying to figure out how to cover using outcomes-based contracts? If we say we pay for value, this is where we prove it—tie payment to outcomes and make access depend on results, not list price. The next milestone is the CEPAC meeting on November 13.
B To D, Or Not To D. This week in Health Affairs Forefront, R. Brett McQueen examined what could happen if Medicare Advantage (MA) plans shifted certain clinician-administered drugs from Part B to the Part D benefit. The analysis walks through consequences for benefit design, sites of care, and patient cost exposure—where a Part D framework would introduce formulary management, pharmacy contracting, and accumulator dynamics that don’t exist under Part B’s buy-and-bill.
For pharma and patients, the tension is obvious: potential care-coordination gains and plan control versus new utilization gates and different out-of-pocket math for infused and injected products. No rulemaking yet (or anytime soon?), but it’s worth stress-testing our top infused drugs under a Part D design so we’re not surprised by benefit changes later.
Double-edged s(Word). This week Health Affairs (sponsored content with the National Minority Quality Forum) spotlighted how state Prescription Drug Affordability Boards (PDABs) can prioritize budget targets over patient need. From a patient-advocacy lens, the risk is that single-threshold “affordability” ignores that patients are heterogeneous. The paper also highlights how PDABs have consistently ignored patients and advocacy organizations, something I’ve heard repeatedly from those trying to talk to PDABs.
The action item isn’t to abandon affordability, but rather to modernize methods and data so PDABs can better distinguish between waste and warranted spend. Many PDABs are still building processes; the lever is statutory guardrails making sure there are patient-centered evidence standards, rare-disease carve-outs, and transparent appeals. We are just at the start of the PDAB implementation (we see you Colorado and Maryland), and we owe it to patients to get it right. The goal isn’t to stop affordability efforts; it’s to shape them—make room for rare conditions, real-world evidence, and patient input from the start.
Generics, The Quiet Workhorse. On Thursday, the National Pharmaceutical Council (NPC) released a Policy & Evidence Brief on “Generic Entry and the Early Impact on U.S. Pharmaceutical Spending”, quantifying how spending patterns shift two to three years after loss of exclusivity. The overlooked story: generics do the heavy lifting on affordability, but policy debates often fixate on launch prices and miss the durable savings from mature competition.
For patients and payers, this underscores why timely generic entry and contracting that passes savings are so important. Our next checkpoint is how 2026 formularies incorporate new entrants in crowded classes.
Reviewing the Fundamentals:
Medicare Advantage Isn’t the Villain—and Original + Medigap Isn’t a Simple Rescue
I can’t believe I’m about to do this, but I feel inclined to defend Medicare Advantage? On Monday evening I sat down with my husband to watch John Oliver and was excited to see the main story was on Medicare Advantage (MA). But it felt like any news story when you know too much about how the sausage is made; the critiques, while fair, don’t tell the whole story. (Am I the only one who talks at the screen?) John Oliver’s segment hit on prior authorization hurdles, network volatility, and marketing claims that oversell. Those problems are real and deserve scrutiny. MA is NOT perfect.
What got lost, however, is that the alternative – Original Medicare with or without Medigap and a standalone Part D plan (PDP) – is not necessarily a frictionless solution. In many markets and for patients, it may introduce a different set of operational and financial risks.
Start with access. Original Medicare’s open network is, on paper, the easiest path to specialist choice. Yet access to that openness is functionally mediated by Medigap, and in most states, Medigap access outside of guaranteed-issue windows remains subject to medical underwriting and premium stratification. That means beneficiaries with recent diagnoses may face denials or pricing that makes switching difficult. (To be fair, he did cover this in the story.)
Prescription drug coverage adds another layer. Moving off an MA-PD plan into Original Medicare requires engagement with standalone PDPs, a market segment that has contracted in recent years and continues to rely on formulary management, preferred pharmacy networks, and utilization controls of its own. Recent changes like the out-of-pocket cap came with access friction like tiering changes, exclusion lists and more utilization management (prior authorization, quantity limits and step therapy). These changes are also happening in MA-PD plans but, typically, MA-PD plans are more generous than PDP plans. There is also the question about the future of PDP premiums once the demonstrations end.
Cost predictability is another area where the narrative often oversimplifies. MA does provide a defined maximum out-of-pocket (MOOP) for Part A/B services, a feature Original Medicare lacks. That ceiling, combined with the bundling of supplemental benefits -dental, vision, hearing, transportation, OTC stipends – creates a cash-flow profile many households find easier to manage. By contrast, Original + Medigap + PDP spreads risk across three contracts whose pricing and rules can move independently and move up year over year.
Care coordination is also a sticky wicket in this conversation. Managed care can be incredibly frustrating when it blocks services or adds paperwork. It also can enable structured transitions between sites of care. Performance varies widely by plan and market, and criticism is warranted when coordination becomes obstruction. Still, for many members, the presence of a dedicated quarterback of care improves the odds that recommended care happens. I will also point out that prior authorization is making an appearance in Original Medicare now through the WiSER model.
To be clear, it feels weird to be defending Medicare Advantage. But for a meaningful segment of beneficiaries, Medicare Advantage can deliver more predictable cash flow and acceptable access. For beneficiaries that require or prefer broader access, Original Medicare with Medigap is terrific, provided underwriting can be cleared and premiums remain sustainable, and provided the PDP market continues to offer options and affordable premiums.
Oliver’s critique highlighted genuine pain points. The remedy, however, is not a universal pivot back to fee-for-service. For now, it is up to the beneficiary to take the time to try and understand their choices – once they get into Medicare Advantage, there may not be a better option. But, in the larger policy scheme of things, it is time to revisit the rules around Medigap and Medicare Advantage so that beneficiaries aren’t trapped by decisions made at a point in time.
For the Win
I needed a dose of optimism, and I am sure I’m not the only one. Here is a lovely NYT story (gift link) on NFL players who go on to be nurses during retirement.
