The MRIoA Resource Center

• Gold Card and other key regulatory requirements become effective 1/1/24 in 8 states.

• ClearPath Optimal list identifies 240 high codes accounting for $66 million in annualized medical spend per 100K lives
• Here are 10 CPT codes that we commonly see on the prior authorization list that could be removed to lessen the burden on providers, patients and ultimately administrative work for payers.  The top 10 codes are:
  • 46948
  • 46707
  • 57106
  • 43233
  • 43245
  • 43214
  • 46607
  • 43246
  • 43241
  • 43215

• Innovative strategies in managing high-cost specialty medications (including GLP-1s can significantly impact plan drug spend)
• Ozempic shows clinical benefit in patients with heart failure
• The PBM marketplace is more competitive than ever. High levels of satisfaction can increase customer retention and lifetime value,¹ so customer satisfaction is a key differentiator. Drug benefit management is increasingly complex, and plan sponsors depend on PBMs to deliver services seamlessly and help control costs.²
  A few key data points to ponder²
  • Overall satisfaction is at its lowest point since 2014
  • NPS decreased to 8 in 2023 and varies by respondent group
  • PBMs have room to improve in helping plans address the affordability of high-cost gene therapies
  • Respondents see both strengths and weaknesses of disruptive solutions like Amazon Pharmacy and Cost Plus Drugs

1 Otto AS, Szymanski DM, Varadarjan R. Customer satisfaction and firm performance: insights from over a quarter-century of empirical research. J. Acad. Mark. Sci. 2020;48:543-564.
2 Pharmacy Benefit Manager Customer Satisfaction Report

• GLP-1 drugs have off-label support for heart failure¹; heart attack and stroke²
• There is a trend to reduce prior authorizations (PA) at health plans, TPAs and PBMs. MRIoA can help eliminate low value PAs

1 Semaglutide in Patients with Heart Failure with Preserved Ejection Fraction and Obesity
2 Novo’s Wegovy shows heart benefit alongside weight loss in trial