Advocacy Groups Raise Concerns About TrumpRx and PBM Prices
The Arthritis Foundation and the HIV+HEP Policy Institute sent a joint letter on Friday, August 21, to the head of the Pharmaceutical Care Management Association (PCMA), which lobbies on behalf of pharmacy benefit managers (PBMs). The letter requests that PCMA work with its PBMs to ensure that drugs purchased via TrumpRx count towards enrollees’ deductibles. PCMA has an agreement with 10 PBMs to present the discounted TrumpRx drugs to enrollees. As it stands, if an individual purchases a prescription drug directly from TrumpRx, it does not count towards their deductible or out-of-pocket (OOP) maximum. The advocates argue that patients cannot “meaningfully compare” the purchase price of drugs between TrumpRx and their insurance, with direct purchasing possibly increasing their costs later on due to not reaching their deductible or OOP maximum.
While there has been some movement via the Federal Trade Commission and Congress, no formal legislation or regulation has been produced. Thus, the Arthritis Foundation and HIV+HEP Policy Institute request that PCMA move forward with their plans to establish a process that allows enrollees to submit proof of payment and receive credit on their policies. Similar cost-sharing protections exist in Connecticut and Colorado, allowing qualified drug purchases to count toward an enrollee’s spending limit. Finally, the letter highlights how providing both TrumpRx and traditional PBM drug prices may impact medical loss ratio calculations, actuarial values, and premium costs (Inside Health Policy, August 21).
CMS Requires Nine States to Submit Plans to Discontinue Gender-Affirming Care Coverage under Medicaid and CHIP
Following CMS’ rule banning the use of Medicaid funding for gender-affirming care to minors, CMS Administrator Mehmet Oz sent letters to the governors of California, Massachusetts, North Carolina, New Hampshire, New York, Ohio, Oregon, Pennsylvania, and Washington. The letter requires the states to explain how they will discontinue use of federal funding for gender-affirming care, and how they plan to revise Medicaid and CHIP policies, and related changes to claims processing, managed care contracts, and drug lists. The letters also request information on states’ system to both monitor compliance and notify affected individuals and health plans. Responses are due back to the department by October 1, two weeks ahead of the effective date of October 13 (Inside Health Policy, August 20).
States Weigh Medicaid GLP-1 Coverage as Costs Rise
State Medicaid programs are debating whether to participate in the Trump administration’s effort to expand access to GLP-1 weight-loss drugs, with cost and budget pressures shaping many of those decisions. Twenty-nine state Medicaid programs told POLITICO they will not participate in the federal model, while Indiana is the only state that has publicly signed on and seven others are still considering participation. Medicaid spending on GLP-1s increased from about $1B in 2019 to nearly $9B in 2024. States are required to cover the drugs for certain conditions, including diabetes and heart disease, but coverage for weight loss alone remains optional.
Twelve states currently cover GLP-1s for weight loss, although five states ended coverage over the past year and Rhode Island plans to end coverage in October amid concerns about rising costs. California, for example, ended coverage after projecting costs could reach $800M by 2028 to 2029. Under the federal model, states would receive Wegovy at a negotiated price of $245 per monthly dose and adopt standardized eligibility criteria, including a BMI of 35 or higher. Some states said participation would still require significant new spending, while others may prefer to negotiate their own pricing and coverage terms directly with manufacturers (Politico, August 22).
CMS Medicaid Deferrals Raise Questions for HCBS Access
CMS’s Medicaid payment deferrals in California and Minnesota are drawing attention to how program integrity actions could affect home- and community-based services. Centers for Medicaid and CHIP Services Director Daniel Brillman said states could reduce or eliminate HCBS waitlists by addressing fraud and reinvesting the savings. His comments came as CMS moves forward with a combined $1B in deferrals involving the two states. California’s initial deferral affected its In-Home Supportive Services program, while Minnesota’s deferrals have focused on personal care, HCBS, and other services that CMS identified as high-spending or rapidly growing. Minnesota has since paused new provider enrollment in 12 high-risk service areas, frozen new adult day center licenses for two years, and restricted new licensing or enrollment for certain HCBS and behavioral health programs. Disability advocates say access challenges are also tied to workforce shortages and limited investment in community-based services. ANCOR estimates that more than 552,000 people with intellectual and developmental disabilities remain on waiting lists and said program integrity efforts should be targeted carefully to avoid further limiting access to care (Inside Health Policy, August 24).
