JUNE 3, 2025
Originally published by our sister publication Specialty Pharmacy Continuum
By Karen Blum
Managing overall specialty drug costs and total cost of care are the top goals in specialty management expressed by 84% of employers and health plans, according to results of the 2025 Trends in Specialty Drug Benefits Report by the Pharmaceutical Strategies Group (PSG), a pharmacy intelligence and technology company. Highlights from the report were presented in a recent webinar.
This figure is an
Originally published by our sister publication Specialty Pharmacy Continuum
By Karen Blum
Managing overall specialty drug costs and total cost of care are the top goals in specialty management expressed by 84% of employers and health plans, according to results of the 2025 Trends in Specialty Drug Benefits Report by the Pharmaceutical Strategies Group (PSG), a pharmacy intelligence and technology company. Highlights from the report were presented in a recent webinar.
This figure is an increase from 75% of survey respondents selecting these goals the previous year, said Morgan Lee, PhD, MPH, CPH, the senior director of research and strategy for PSG. “That shift really reflects growing concern about the rise in pharmacy benefit costs and the urgency of implementing strategies to manage those costs,” Dr. Lee said. Reducing out-of-pocket costs and inappropriate utilization, and increasing transparency, rounded out the top five concerns.
The online survey, conducted in fall 2024, queried 231 benefits leaders representing employers, health plans and unions/Taft-Hartley plans with a median of 10,000 covered lives. Employers made up the largest portion of respondents (71%), followed by health plans (24%). The majority of the respondents (69%) used one of the three largest pharmacy benefit managers (PBMs)—CVS, Express Scripts or OptumRx—to administer their prescription drug programs.
Looking at the top specialty drug management challenges, respondents said affordability of specialty drug cost-sharing amounts for members, access to reliable data on the total cost of care impact of medications, and access to actionable integrated pharmacy and medical data ranked highest. Compared with last year, health plans and employers noted greater difficulties with integrated data access and biosimilar strategy implementation, Dr. Lee said.
Integrated data “is the power that, when combined with clinical expertise, leads to the development of strategies and solutions we use to help our clients better manage their drug spend,” said Renee Rayburg, RPh, the vice president of clinical strategy for PSG.
About 72% of plans reported that they now have a medical drug formulary, and 77% of plans reported that they have processes in place to manage their specialty formulary across their pharmacy and medical benefit. “These findings highlight the growing importance of having comprehensive formulary management strategies,” Dr. Lee said.
The following are findings in other categories:
Utilization management strategies. The most commonly used program by nearly all (95%) respondents was prior authorization, followed by step therapy (83%) and quantity limits (83%), while the least commonly used strategies were shifting specialty drugs from the medical to the pharmacy benefit (26%) and using niche specialty pharmacies to manage certain conditions (24%). Smaller employers were less likely than larger ones to use each of these strategies, Dr. Lee said, sometimes with “substantial differences.”
For example, 70% of smaller employers versus 88% of larger employers used step therapy, and 45% of smaller employers versus 63% of larger ones used copay accumulator programs.
When used properly, utilization management “can be a really valuable tool to ensure appropriate use,” Ms. Rayburg said. However, prior authorization “should not serve as a barrier to access to drugs.”
Site of care programs. Just over one-third (36%) of respondents are using site-of-care programs that shift patients from higher-cost drug administration settings, such as a hospital, to lower-cost channels like home infusion, Dr. Lee said, and 20% said they were considering it for the future. Among those with site of care programs, mandatory arrangements have been implemented by 56% of respondents-a jump from 46% the previous year.
Oncology management. Due to the complexity of cancer treatment for both patients and payors, some payors are using oncology management vendors to help with adherence to recommended clinical pathways or provide direct patient assistance, Dr. Lee said. In new questions for the survey related to this area, 30% of survey respondents said they are using oncology management vendors and another 26% said they were considering this approach.
Biosimilars usage. More than half (58%) of respondents are employing a lowest net cost strategy, 41% mandate biosimilars for patients new to therapy and 37% mandate conversion of patients on branded bio-logics to biosimilars, the survey found. “Health plans were more likely than employers to be using each of these strategies,” Dr. Lee said. About 72% of respondents are implementing preferred strategies for biosimilars for adalimumab (Humira, AbbVie), either using standard formularies from a PBM that determines coverage or managing their own custom formulary.
Novel cell and gene therapies. In the survey, 73% of respondents said they anticipated affordability of novel cell and gene therapies to be a challenge within the next two to three years, and a significant percent-age (69%) said they had low to moderate understanding of the current cell and gene therapy pipeline, although there was more knowledge among health plan respondents than employers, Dr. Lee said. “It really suggests that benefits leaders need more education and also more data to truly understand their risk for a gene therapy claim and what the impact of a claim would be.”
Cost a Top Concern
Specialty medication cost “remains a top concern for our clients,” commented Kristen M. Reimers, RPh, the senior vice president for specialty clinical solutions at Prime Therapeutics, a pharmacy benefits company in Eagan, Minn. “Similarly, our clients look to us for strategies to manage medication access and affordability. We help ensure that members receive the most cost-effective medications to treat their conditions.”
Blues plans and employer groups that Prime works with also are “committed to whole-person care that smooths out the path from prescribing to dispensing/administration to persisting with therapy as directed,” Ms. Reimers added. To that end, Prime operates a variety of programs to provide education, clinical man-agement and help with accessing affordable medications.
The Trends in Specialty Drug Benefits Report was co-sponsored by Genentech. The speakers reported no relevant financial disclosures beyond their stated employment.
