Payers Are Bracing for the Specialty Trend of the Future | AMCP Nexus 2025

In the last 20 years, more than 1,000 novel drugs have been launched globally, including almost 400 in the past five years. In the United States in 2024, 48 novel drugs were launched, representing a 22% increase from the 2015 to 2019 period. Specialty biologic drugs are expected to have an impact on spending.

Specialty medicines will represent about 46% of global drug spending by 2029 and 54% in developed markets, according to IQVIA’s most recent Global Use of Medicines report.

The upcoming specialty pipeline is large and spans multiple high-impact areas, including immunology, multiple sclerosis, and cell and gene therapies, according to a presentation by researchers at Prime Therapeutics that was presented at the Academy of Managed Care Pharmacy (AMCP) Nexus. The meeting was held at the Gaylord National Resort and Convention Center in National Harbor, Maryland.

This will have a significant impact on payers. The escalating prescription drug spend is primarily driven by increasing utilization and treatment cost, as well as the introduction of novel therapies. The per-member-per-month trend will also continue to rise across the medical and pharmacy benefits, Prime researchers said during their presentation.

“The specialty space will continue to grow. We have seen growth over the past decade, and we will continue to see that trend,” Yuqian Liu, Pharm.D., senior director, specialty clinical solutions at Prime Therapeutics, said in an interview.

Managed care, she said, will be challenged to find the right tools to manage through this innovation and be able to bring them to patients. “There is no way that our healthcare system can keep up with that growth,” Liu said. “It’s up to the managed care professionals to see what we can do through innovation: What additional tools can we utilize to be able to keep the trend down? I don’t anticipate we’ll be able to decrease the trend, but maybe we can slow it down or flatten it.”

Liu and her colleague Soumya Vishwanath, Pharm.D., formulary management director at Prime Therapeutics, presented and discussed the pipeline during their presentation.

This spoke with Managed Healthcare Executive before the Nexus meeting; below they provide an overview of the specialty market to come.

Q: What are the biggest trends in specialties in the short term and long term?

Liu: According to our forecast, autoimmune diseases and multiple sclerosis will continue to be the driver for both medical and pharmacy benefit trends over the course of the next three years. In the long term, cell and gene therapies and rare diseases will likely lead the trend long term. There is a lot of cell and gene therapy in early product development. More than 40% of all the drugs in development are for rare disease indications.

Q: How are payers approaching coverage of autoimmune and MS therapies? What are their strategies?

Liu: Biosimilars are definitely a part of the approach for autoimmune. There is a huge trend in the market to drive toward biosimilar utilization in the autoimmune space. There continues to be a place for novel brand products in both autoimmune and MS. We are seeing first-generation and second-generation products, as they have their unique benefits and patient populations that can benefit from them. These [branded] products will continue to be trend drivers in the market.

There’s a fine balance between clinical efficacy and the cost. Managed care has tried to find the balance between the quality of care and the cost. Biosimilars have their rightful place as the most cost-effective agents on the market. They still are efficacious.

For MS, we see a generics-first strategy. The brand products will continue to have a substantial amount of utilization, but generic products are the most cost-effective.

Q: How are payers looking at gene therapies?

Vishwanath: Cell and gene therapies are being developed for a lot of rare diseases that don’t have any treatments at the moment. These are really innovative products that are going to be coming to the market.

But payers are facing the growing pressure of managing the complexity of these products. They are looking at balancing the cost and the affordability but also recognizing that a lot of these products have very highly individualized care pathways for our patients and for the ecosystem in general. There is going to be a blending of the traditional management approach with utilization management, but also taking a little bit more of an innovative approach to ensure we have access for our patients.