White bagging is a new tactic by health insurers requiring certain medications to be purchased through specialty pharmacies, often owned by the insurance company, with no input from the physician, and then the PBM ships those drugs to the doctor instead of using the drugs doctors have on hand....

Step therapy, or “fail first”, is a policy used by health insurers that requires patients to try and fail one or more formulary-covered medications before providing coverage for the originally prescribed non-formulary or non-preferred medication. Insurers implement this policy in an effort to try to...

While PBMs were originally set up to control drug utilization and cost, they have since become incredibly effective at negotiating discounts and rebates from manufacturers that they keep for themselves as profits rather than passing those savings onto patients. As a result, patients are paying cost-...

Formulary-Driven Switching refers to a policy used by insurers to limit prescription drug coverage to the less expensive medications. It can be used to alter a patient’s medication to the less expensive option during the current contract without any physician or patient consultation....

What are they? Accumulator Adjustment Programs (AAPs) are tools utilized by insurers and pharmacy benefit managers (PBMs) to exclude co-pay assistance as an out-of-pocket expense. This, in turn, excludes co-pay assistance from being applied to a patient’s deductible....