The White House recently announced deals with Eli Lilly and Novo Nordisk to reduce pricing on GLP-1 medications. Medicare beneficiaries will pay no more than $50 per month  for approved treatments like Zepbound and Ozempic. In this announcement, the White House stated Ozempic, Wegovy, Mounjaro and Zepbound Medicare program costs will drop to $245, a significant reduction from current prices, without rebate considerations. Eli Lilly cites copay caps to start as early as Apri

The CY2026 CMS Readiness Checklist was released November 4.  Each year, the Centers for Medicare & Medicaid Services (CMS) releases its Annual Readiness Checklist, outlining the operational, regulatory and compliance requirements that Medicare Advantage (MA) and Part D plans must have in place for the upcoming year. While many elements are consistent year over year, CMS routinely adds new items and clarifies expectations based on evolving regulations and program priorities. T

As Medicare Part D oversight continues to intensify, formulary and benefit coding errors by Pharmacy Benefit Managers (PBMs) remain a top compliance risk for Plan Sponsors. Ensuring that claims adjudicate accurately to your CMS-approved formulary and benefit design is not just a best practice — it’s a compliance expectation. Annual benefit administration testing (BAT)  continues to be one of the most effective tools to validate the accuracy of your Part D benefit before the p

Cigna’s new pricing strategy raises important questions about the future of pharmacy benefit management. Beginning in 2026, the company plans to introduce a cost-plus reimbursement model for pharmacies, followed by a 2027 rollout of technology-driven price comparisons for Commercial customers—eliminating traditional rebates in the process. As specialty drug costs continue to rise, PBMs remain under increased scrutiny. Transparent pricing is no longer optional—it’s essential

What Was Vacated and Why It Matters   On September 25, 2025, a federal court in Texas vacated the Centers for Medicare & Medicaid...

NCQA just released its 2025 Health Plan Ratings, and the results send a clear message: success in today’s Medicare Advantage and...

CMS just announced a major change that will affect all Special Needs Plans ( SNP s) beginning with Contract Year (CY) 2027. Starting in...

As we enter the second half of the year, it’s time to prioritize one of CMS’ most important requirements for Medicare Advantage and Part...

As we approach 2026, the Centers for Medicare & Medicaid Services (CMS) has released critical updates to the Medicare Advantage (MA) and...

CMS’ 2024 Part C & Part D Program Audit and Enforcement Report is out—and it’s full of critical insights every Medicare Advantage (MA)...

In today’s complex healthcare landscape, data isn’t just numbers—it’s the key to delivering personalized, impactful care. At RISE...

The June 2nd initial bid submission deadline for 2026 has passed, and Medicare Advantage plans were faced with a series of complex...

The Centers for Medicare & Medicaid Services (CMS) has issued formal deadlines for the submission of closed period deletes to the Risk...

Insights from the 2025 RISE Risk Adjustment Forum As CMS ramps up oversight and plans prepare for V28 and RADV expansion , the 2025 RISE...

CMS has just announced a major expansion of its audit program for Medicare Advantage (MA) plans—shifting from sampling a few contracts to...

In April 2025, the Centers for Medicare & Medicaid Services (CMS) issued a significant round of enforcement actions impacting a wide...

CMS has issued an HPMS memo  titled: “Deadlines for Submitting Risk Adjustment Data for Use in Risk Score Calculation Runs for Payment...

The Centers for Medicare & Medicaid Services (CMS) have introduced significant updates to the Hierarchical Condition Category (HCC) risk...

As of January 2025, the Centers for Medicare & Medicaid Services (CMS) imposed civil monetary penalties on several Medicare Advantage and...