Swearing Off Rebates? Payers Say They Are Interested but Not Giving Them Up Just Yet | Asembia AXS25

Payers are increasingly open to alternatives to traditional rebate programs. About 80% are interested in lower-cost drugs that offer no rebate at all, and more than 60% are interested in cost-plus pricing models, according to Pharmaceutical Strategies Group’s (PSG) newly released 2025 Trends in Specialty Drug Benefits Report. The report was presented at Asembia’s AXS25 Summit in Las Vegas in April 2025.

At the same time, two-thirds of those who responded to the PSG survey said their plan has experienced an increase in the amount of rebates received in the last one to two years under the pharmacy benefit for specialty drugs, and just over half saw an increase under the medical benefit.

Morgan Lee, M.P.H., Ph.D.

The report, co-sponsored by Genentech, was based on an annual survey conducted in September and October 2024. The survey included 231 benefit leaders from employers, health plans, and unions.

Morgan Lee, M.P.H., Ph.D., senior director of research and strategy at PSG, pointed out, however, that this may not take into account payers’ experiences with the Humira biosimilars. “We had asked respondents to project backwards over the last one to two years, and they may have not really been engaging with the Humira biosimilars,” she said in an interview with Managed Healthcare Executive (MHE).

Biosimilars to Humira (adalimumab) came on the market in 2023. Starting with the first, Amgen’s Amjevita (adalimumab-atto), many of these Humira biosimilars have had two prices, a high list price with a rebate and a lower one without.

“We’re seeing moderate interest in those alternatives, especially that idea of preferring those lower list price drugs that aren't going to offer a rebate or not as big of a rebate,” Lee said. “Some of our respondents say their interest is increasing year-over-year, but we’re still seeing relatively few that are actively implementing strategies [without rebates].”

Lee said that about a third of respondents to the survey are actively working to implement rebate alternatives. “It’s hard to move away from rebates. That’s part of why we see it being a little bit slow in terms of the real movement there.”

PSG is beginning to see a shift with some payers accepting lower guarantees in terms of rebates in exchange for implementing more utilization management, said Lee: “They believe this will better help with the appropriate use of these drugs.”

Rebekah Gregg

In the future, the number of payers who receive rebates may start to decline as more consider low-list-price biosimilars and as they begin to see more models without rebates, noted Rebekah Gregg, MBA, chief operating officer of PSG.

“Our drug purchasing economy is so entrenched with rebates, but payers haven’t been presented with a mature model that doesn’t have rebates at the core,” she said in an interview with MHE. The use of rebate alternatives depends on “the maturation of the employer or the healthcare payer,” Gregg added. “Still, payers get opaque data on how much they spend on medications, and how those rebates are translating at a drug level is rarely very clear.”

Access to reliable data on the total cost of care continues to be a top challenge for payers who responded to the PSG survey. Gregg said that payers want to understand what was invested in particular therapy and “whether a cohort of patients that receive this therapy have better health outcomes and lower total cost of care than other patients that maybe didn’t get this high-cost therapy.”

Gregg pointed to a review done by Artemetrx, a PSG company, of the multiple sclerosis drug Ocrevus (ocrelizumab) as an example of the data that payers are looking for. In PSG’s Specialty Trend report from 2022, Artemetrx compared total cost of care (including drug costs, hospitalizations, and physician visits) for 2020 and 2021 for patients who switched to Ocrevus. They found that the total cost of care declined from $103,196 in 2020 to $90,667 in 2021 for patients who switched.

Some employers and health plans are changing how they manage expensive medications, with 84% of respondents saying managing specialty drug costs or total cost of care is their top priority, up from 75% last year.

Another top challenge of payers in the PSG survey is access and affordability of specialty drugs. Managing the overall specialty spending and trend and especially drug cost is payers’ No. 1 or No. 2 goal for more than 70% of respondents.

“This speaks a bit of the tightrope that we see healthcare payers walking,” Gregg said. “Special drugs are oftentimes treating complex and rare diseases. Healthcare payers understand that ensuring access to those drugs is incredibly beneficial in terms of overall total cost of care and improved clinical and financial outcomes. But affordability is an issue for them. Managing that trend and making sure that members are on the appropriate therapy is a high concern.”

[sidebar]

One-third of payers shift site of care for specialty drugs

Health plans are more likely to have programs to shift care for specialty medications from higher-cost hospital settings to lower-cost options than employer groups, according to PSG's 2025 Trends in Specialty Drug Benefits Report.

Among all payers, just over a third reported they have site-of-care programs in place for specialty medications; 20% were considering site-of-care programs for the future.

Of the payers who do use a site-of-care program, 56% of plans made this mandatory for patients, an increase from 46% last year. This shift was driven by a large increase among employers, and many payers who shifted to mandatory programs previously had a voluntary program with incentives, according to PSG.

“Many of those who are currently using [site of care programs] are interested in expanding their site of care,” said Lee.

This year, PSG specifically asked about site of care programs in oncology, and only about 5% of respondents currently have programs to shift care out of the hospital setting for those with care.

“But of the 95% that weren’t [using site of care programs], over half said that they would be at least moderately willing to look into site of care for oncology,” Lee said.

Payers had a hands-off approach to oncology, said Rebekah Gregg, chief operating officer of PSG. “Healthcare payers are sensitive about the cancer population and not being disruptive to these patients. Now, we have more therapies on the market for oncology, and with the maturation of the entire market, healthcare payers are looking at some cost management strategies for oncology.”

But Gregg said it’s too early to know whether home infusion of cancer medications will grow in the near term. “Hospitals especially feel very passionately that when they're able to manage the care continuum for the patient, they're able to provide better outcomes.”