Waiting for Your PBM to Tell You What Changed Isn’t a Strategy Most plan sponsors receive annual formulary updates from their PBM, review the member disruption report, and move forward. What they often don’t receive is the financial analysis behind those changes: the net cost impact, the alternatives that were considered, or whether those decisions … Your PBM Tells You What Changed. Who’s Telling You Why?
Every year, you get the same notification from your PBM: “Here are your formulary changes and here is the member disruption.” That’s all. Most plan sponsors absorb the changes, notify their members, and move on. What they don’t get is the financial analysis behind why those decisions were made: not the net cost impact, not … Waiting for Your PBM to Tell You What Changed Isn’t a Strategy
PBM reform is often framed as a policy story. But for health plans and payers, it’s really a stress test: can their pharmacy strategy withstand a market where pharmacy benefit structures are becoming easier to see, question, and connect back to plan performance? As new federal requirements, enforcement activity and state-level regulation put more pressure … PBM Reform Is Exposing the Limits of Legacy Pharmacy Strategy for Payers
This month’s edition provides a focused review of newly approved and recently launched therapies. Expion Health monitors these developments closely to assess clinical relevance, therapeutic positioning, and potential implications for payers, providers, and patients. Indication YUVIWEL (navepegritide) is FDA approved to increase linear growth in pediatric patients aged 2 years and older with achondroplasia and … Rx Insights from March ’26
The future of pharmacy benefits is moving toward greater transparency, and that’s good news for employers, members, and the partners who support them. The FTC’s recent settlement and regulatory actions are raising expectations around reporting, visibility, and accountability across the drug benefit ecosystem. These changes will give employers clearer insight into drug level economics and … Pharmacy Benefits Transparency Isn’t the Future. It’s the Foundation.
This month’s edition provides a focused review of newly approved and recently launched therapies. Expion Health monitors these developments closely to assess clinical relevance, therapeutic positioning, and potential implications for payers, providers, and patients. IndicationARMLUPEG (pegfilgrastim-unne) is an FDA-approved biosimilar to Neulasta (pegfilgrastim) indicated to reduce the risk of infection, as manifested by febrile neutropenia, in … RX Insights from December ’25
Instead of our traditional fun-and-games holiday party, we launched the Expion Elves Holiday Challenge. And it became one of the most meaningful moments of our year. At Expion, our culture is built on ideas, and this one came directly from one of our own. We broke into teams, and each team chose an organization close to their … Turning the Holiday Celebration Into Meaningful Impact
This month’s edition provides a focused review of newly approved and recently launched therapies. Expion Health monitors these developments closely to assess clinical relevance, therapeutic positioning, and potential implications for payers, providers, and patients. KYGEVVI Indication KYGEVVI is approved by the FDA for the treatment of thymidine kinase 2 deficiency (TK2d) in adults and pediatric … Rx Insights from November ’25
Qlare™ Data Assistant coming soon to ExpionIQ®
This month’s edition provides a focused review of newly approved and recently launched therapies. Expion Health monitors these developments closely to assess clinical relevance, therapeutic positioning, and potential implications for payers, providers, and patients. KEYTRUDA QLEX Indication KEYTRUDA QLEX (pembrolizumab and berahyaluronidase alfa) is approved for the treatment of 38 indications, including melanoma, non–small cell … Rx Insights from October ’25
When it comes to your professional journey, staying vigilant is crucial. At Expion Health, we prioritize your safety and want to ensure you are equipped to identify and report potential job scams. Here are 4 valuable tips to keep in mind: ⓵ Verify the source: Be cautious of unsolicited emails or text messages claiming to represent a … Tips to Protect Yourself from Job Scams
BRENTWOOD, Tenn., and GAITHERSBURG, Md., October 3, 2024 – Today ClarisHealth, provider of the leading integrated payment integrity technology platform for health plans, announced a strategic partnership with Expion Health. ClarisHealth is pre-integrating Expion Health into the Pareo® platform to offer enhanced out of network (OON) claims management capabilities designed to detect and avoid more claims overpayments without … ClarisHealth Partners with Expion Health to Offer Enhanced Out of Network Claims Management Services on the Pareo® Platform
It’s not uncommon for facilities or PPO networks to assert that a claim is DRG-based to deter payors from pursuing further review. On the surface, this might seem like a dead end for an Itemized Bill Review, but that’s not always the case. When informed that a claim was repriced at a DRG, it’s crucial … The Power of Probing: Why You Should Question DRG-Based Claims
The concept of ethical administration has rapidly become a hot topic – so much so that it is the theme of this year’s Health Care Administrators Association (HCAA) TPA Summit. This post, inspired by insights from Nicholas Stone, SVP, Medical Cost Containment Sales at Expion Health, examines what constitutes “Ethical Administration,” aiming to highlight the … Choosing the Right Partners: Administrators’ Quest for Vendors Committed to Ethical Administration in Non-Network Claims
Expion Health is pleased to announce our strategic partnership with HUB International, which was launched at HUB’s Clinical and Pharmacy Conference. As a preferred partner, Expion Health will provide expertise in medical bill review, independent reviews, and actionable insights for strategic pharmaceutical initiatives, complemented our powerful, award-winning ExpionIQ analytics. Nick Stone, SVP, Medical Cost Containment … Expion Health Announces Strategic Partnership with HUB International
In the changing landscape out-of-network (OON) medical claims, health plans & TPAs face the dual challenge of managing costs while ensuring fairness and transparency. A recent New York Times article spotlighting practices by certain industry players has intensified concerns regarding the management of OON claims. Such revelations underscore the importance of adopting business practices that … Navigating Shifting Market Expectations: Enhancing OON Claim Repricing Fairness and Transparency
Expion Health’s analysis of the latest CMS report from February 2024, which sheds light on the Independent Dispute Resolution (IDR) process for No Surprises Act (NSA) cases. for the first half of 2023, uncovered a particularly interesting finding: plan dollars are being wasted on what we have termed “no-response” claims. These occur when health insurance … NSA No-Response IDR Determinations a Surprising Waste of Plan Dollars
A central theme emerged, at the HCAA Executive Forum: the imperative for TPAs to evolve as a fiduciary-like partner for their groups and their employees. In this dynamic landscape, the call for transparency and control in medical claims and administrative costs has never been louder or clearer. A New Paradigm for TPAs In the face … Harnessing Transparency and Control: Key Takeaways from the HCAA Executive Forum from Expion Health
The Federal government recently proposed changes to the NSA IDR process in hopes of holding all involved organizations more accountable and forcing initiating and non-initiating parties to be more diligent in documentation and timely admin fee payments. While the end goal may be to increase speed, efficiency, tracking and transparency, the immediate result is health … Get Ready: CMS Proposes Numerous Changes to IDR Process
Today, Expion Health, a pioneer in leveraging powerful technology and dynamic pricing strategies, unveiled its new collaboration with Mark Cuban Cost Plus Drug Company, PBC (Cost Plus Drugs). This strategic alliance will integrate Cost Plus Drugs’ revolutionary pricing into Expion Health’s product suite, offering an innovative way to tackle the escalating costs of specialty drugs.Karin … Expion Health and Mark Cuban Cost Plus Drug Company, PBC Forge Innovative Collaboration to Enhance Pharmacy Cost Management
The Expion Health team left the Self-Insurance Institute of America, Inc. 2023 Conference energized and inspired. We had insightful conversations with over 40 different organizations and immersed ourselves in thought-provoking speaker sessions. 🔑 The key takeaway: Self-insured groups and administrators are assessing their current approach to managing medical claims costs, leading them to reevaluate their … Expion Insights from SIIA 2023
Expion Health proudly announced it has been named an inaugural UiPath AI10 Award Winner. The UiPath AI10 Awards recognize the 10 best and most innovative uses of AI-powered automation across UiPath’s global customer base. Expion Health was recognized for its AI at Work leadership at UiPath FORWARD VI, UiPath’s annual gathering of global AI and … Expion Health Named Inaugural UiPath AI10 Award Winner
NSA currently excludes Urgent Care and Ground Ambulance services despite pressure to do so. However, some states have begun to provide protection. This means self-funded employers must determine which coverage to use. What may seem like the right path may not always make the most economic sense. To ensure the best savings, self-funded plans should … NSA Minute: Ground Ambulance & Urgent Care Services
Blue Shield’s shift from a single PBM to multiple specialized partners for pharmacy benefits management has health plans wondering if disaggregation is right for them. At Expion Health, we’re here to highlight why this shift matters and how we can support health plans like yours with this strategy. 1. Strategic Alignment: Partnering Without Conflict Moving … Blue Shield of California Pharmacy Shake-Up: 3 Disaggregation Considerations for Health Plans
There are 5 costly challenges payers still face when it comes to NSA claims. These challenges are exposing payers to compliance risks and upsetting members. Expion Health’s NSA Navigator is designed to solve those challenges. Don’t expose yourself to NSA compliance and member satisfaction risks. Understand the top challenges payers face and how to solve … Top 5 NSA Challenges & Solutions for Payers
Payers grapple with the complexities of the No Surprises Act (NSA), but self-insured plans face an added challenge in states that allow plans opt-in to state laws instead of the federal law. Selecting between state or federal laws demands careful analysis of factors such as: breadth of protections, data inputs allowed for payment determinations, claims … Navigating the No Surprises Act: The State vs. Federal Balance Billing Dilemma
Independent dispute resolution (IDR) has gained remarkable popularity among healthcare providers since the implementation of the No Surprises Act (NSA). The statistics from the first year of the NSA reveal an unexpectedly high volume of IDR cases—14 times more than initially projected. As of March 31, 2023, IDR entities have issued a substantial 42,158 payment … Inside the Numbers: The Surging Popularity and Impact of IDR under the No Surprises Act
Expion Health, previously known as Exponent Health, has taken a bold step in the advancement of healthcare technology with the launch of its mobile app, ExpionME, and a strategic company-wide rebranding. The introduction of ExpionME, designed to ease the burden of rising healthcare costs for payers and their members starting with balance billing, signifies the … Expion Health Launches Innovative Mobile App, ExpionME, and Rebrands from Exponent Health
