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.
FY 2026 ICD-10-CM Codes Released
In June, CMS and the CDC announced over 400 new FY 2026 ICD-10-CM codes for patient encounters and discharges. These will address emerging health concerns, enhance clinical specificity, support accurate reporting, and reflect advances in medical knowledge and terminology.
Chronic Care Management in Medicare: Optimizing Utilization
CCM services remain underutilized, but a subset of claims lacking supporting diagnoses suggests opportunities to improve utilization via coding accuracy.
White Paper: Policy Considerations for Refining MA Star Ratings
This paper presents several proposed changes to the MA Stars Rating program and offers insight into how each proposal would impact federal entities, payers, and members.
Research on Opioid Use Reveals States, Local Governments Spend $94 Billion Annually
“The Cost of Addiction: Opioid Use Disorder in the U.S.” is the first-of-its-kind study that reveals state and local governments shoulder a significant financial burden on taxpayers, businesses, and communities.
Commercial Step Therapy May Include Steps Beyond FDA Label
Across three therapeutic areas, an Avalere Health analysis identified commercial plan coverage policies with more steps than indicated by drugs’ FDA labels.
White Paper: Medicaid Reforms’ Impact on Funding for Children’s Healthcare
Avalere Health estimated how three possible changes to federal Medicaid funding could impact national- and state-level funding in total and for children’s services.
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.
New Resource: Commercial Payers’ Use of Oncology Compendia
Avalere’s dashboard provides insights into commercial payer trends for use of clinical drug compendia for off label coverage decisions in oncology.
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.
State Copay Accumulator Bans Now Affect 16% of Commercial Lives
Over 16% of people enrolled in the US commercial insurance market belong to a health plan that must count copay assistance toward patient cost sharing.
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.
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.
Avalere Resource: Coverage and Coding Regulatory Calendar
Avalere’s new CY 2025–2026 Coding and Regulatory Calendar supports life sciences firms’ strategic planning for critical coding deadlines, timelines, and regulatory updates.
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.