Drug Coverage

Managing specialty and cancer drugs, as well as the GLP-1 therapies, tops the list of priorities this year and next, according to a survey by the International Foundation of Employee Benefit Plans.

Two PBMs, True Rx Health Strategies and Capital Rx, are using pharmacogenomics — how a person’s DNA affects their response to medications — to reduce the trial-and-error of prescribing medications, saving employers and patients time and money.

Health policy researcher Geoffrey Joyce argues that only delinking compensation from the list price of a drug will lower drug spending.

Following in the footsteps of other pharmaceutical companies, Bristol Myers Squibb and Pfizer are offering Eliquis for cash-paying patients at a discount of 40% off the list price.

Optum Rx officials said they now have eliminated reauthorization requirements for more than 140 chronic disease medications.

A separate Prime analysis, however, of year-over-year claims data for Wegovy and Zepbound only found an improvement in adherence in 2024, suggesting there is an evolving understanding of obesity treatment.

More than 50 insurers have pledged to streamline and simplify the prior authorization process through six new commitments.

The FDA had resolved the shortage of Wegovy in April, and telehealth providers were advised to stop selling compounded semaglutide products. Novo Nordisk said that Hims & Hers continues to offer these compounded drugs.

A survey by PSG has found that the pressure to control drug costs is leading some payers to look into unbundling pharmacy benefits as a way for better control.

The pharmacy benefit manager (PBM) industry is under pressure to shift to models that avoid conflicts of interest and misaligned incentives.

State efforts are aiming to bring more disclosure and transparency to PBM practices, mandating certain pharmacy reimbursement levels, requiring 100% pass-through rebates, and prohibiting spread pricing.

Pharmacy costs and outpatient facility care generate 69% of the cost increase for 2025, according to Milliman’s recent Medical Index.

Health plan sponsors are also expected to see a reduction in the net cost per prescription of GLP-1 medications to treat obesity.

A new law in Iowa, if signed by the governor, will mandate 100% pass-through of rebates, increased financial transparency, and a minimal payment for pharmacies. Critics say it will be the most costly mandate in the state’s history.

It could improve access to community pharmacies and lower prices. Or it will limit access to critical drugs and impact payers’ ability to contract for a broad range of services. Industry leaders are unsure about the impact of Arkansas’ law banning PBMs from owning pharmacies.

Express Scripts, Cigna, UnitedHealthcare, CVS Caremark and Optum Rx are among the payers that have added Yesintek to their formularies.

Effective July 1, 2025, CVS Caremark will place Wegovy injection 2.4 mg as preferred on its commercial template formularies.

Insurance hurdles and the complexities of prior authorization create barriers to care, according to oncologists in a new survey by Sermo.

Novo Nordisk has teamed up with Hims & Hers Health, LifeMD and Ro for cash-paying patients to access Wegovy injection 2.4 mg through its NovoCare Pharmacy.

Giant Eagle also helped EmpiRx Health create a national pharmacy care network that was purpose-built for pharmacy and grocery chains.

Nationwide, 58% of Medicare beneficiaries living in rural areas are enrolled in stand-alone prescription drug plans in 2025.

A new paper by the Institute for Clinical and Economic Review (ICER) looks at the cost-effectiveness versus affordability issue of obesity medications such as Wegovy and Zepbound.

Bkemv is being offered at 10% off Soliris, and Epysqli is offered at 30% below Soliris. Both biosimilars treat several of the same rare immune diseases as Soliris.

Wegovy is also available through NovoCare Pharmacy, which directly ship all dose strengths at a cost of $499 per month for cash-paying patients.

Optum Rx's new cost-based program uses an internal algorithm that leverages multiple available industry data sources, such as NADAC and PAC, to inform reimbursement.

Optum Rx has eliminated reauthorization for almost 70 drugs for chronic diseases, about 10% of its overall pharmacy prior authorizations.

Steqeyma is one of seven Stelara biosimilars that have been approved by the FDA.

Lumicera Health Services, Navitus’ specialty pharmacy, has made a deal with Teva to offer an unbranded biosimilar that they estimate will save $112,000 and $336,000 per patient per year. Navitus will remove Stelara from formulary on July 1, 2025.

The new bill would also require state Medicaid programs to report National Average Drug Acquisition Costs (NADAC) as a way to increase transparency in drug pricing.

NovoCare Pharmacy will provide all dose strengths of Wegovy at a reduced cost of $499 per month for cash-paying patients without insurance.