Cautionary Tale Reveals New Scrutiny of Pharmacy Benefit Manager, Employer and Insurer Liability for Coverage of Innovative Therapies

Cautionary Tale Reveals New Scrutiny of Pharmacy Benefit Manager, Employer and Insurer Liability for Coverage of Innovative Therapies

October 16, 2023, Employee Benefit Plan Review

A recent district court case, Henkel of America, Inc. v. ReliaStar Life Ins. Co., serves as a cautionary tale for sponsors of self-insured health plans who, while relying on pharmacy benefit managers (PBMs) to set formularies and process certain claims and appeals, and on stop-loss insurers to cover claims above a certain level, may be left addressing significant coverage costs for innovative therapies.