Latest news with #PharmaceuticalStrategiesGroup
Yahoo
2 days ago
- Health
- Yahoo
PSG Releases 2025 Drug Benefit Design Report: PBM Unbundling Gains Momentum and Payers Navigate GLP-1 Coverage Decisions Amid Rising Costs
New Research Reveals Strategic Approaches to Balancing Member Access and Affordability with Pharmacy Spend Control DALLAS, June 10, 2025--(BUSINESS WIRE)--Pharmaceutical Strategies Group ("PSG"), an EPIC company, published its 2025 Trends in Drug Benefit Design Report, delivering critical insights into how payers are navigating a rapidly evolving pharmacy benefits landscape. For three decades, this industry report has been an essential resource for employers, health plans, and other stakeholders seeking to understand and adapt to changes in pharmacy benefit design and management. The 2025 edition addresses both foundational benefit design elements — including formulary and network design, utilization management, and cost sharing — and today's most pressing challenges, such as GLP-1 coverage decisions, heightened fiduciary liability concerns, and the accelerating shift toward unbundled PBM arrangements. Drawing from extensive research and insights from benefits leaders nationwide, the report provides actionable intelligence for organizations working to balance member access and affordability with effective pharmacy spend control. Read all the insights in the full report available here. Navigating the GLP-1 Surge While nearly all plans cover GLP-1s for type 2 diabetes (92%), only 39% currently cover GLP-1s for obesity. Cost is a large concern for payers with respect to GLP-1s for obesity, but even so, the survey finds that nearly half of plans that currently exclude these drugs from coverage say they would not cover the drugs at any price. Benefits leaders must balance the overwhelming demand for these medications with their cost as well as the decision to cover a treatment for obesity. "GLP-1s are the area of this report where we see the most variation in perception and strategy," said Morgan Lee, Senior Director of Research & Strategy at PSG. "Respondents are very concerned about GLP-1 affordability for the plan, and many are concerned about off-label use of GLP-1s for type 2 diabetes, yet nearly half don't know how much of their current spending is for off-label purposes. We're also seeing continued variation in how plans perceive GLP-1s for obesity, whether as lifestyle drugs or as treatments for a chronic disease. As the GLP-1 landscape rapidly evolves with expanded indications, direct-to-consumer offerings, and more, payers will continue to have new considerations and decisions to navigate." Unbundling Pharmacy Benefit Management One of the most disruptive strategies explored in the report is the shift toward unbundling PBM services. This year's report revealed that a growing number of payers are evaluating or already pursuing this modular approach, which allows organizations to separate functions, such as claims processing, formulary management, and rebate negotiation, and contract them independently. "We're seeing rising interest in partial or fully modular PBM arrangements," shared Beth Hebert-Silvia, Senior Vice President, Health Plans Practice Leader at PSG. "This strategy isn't plug-and-play. It requires sophisticated design and execution, but it enables plans to align each element of their pharmacy benefit with their unique needs. More importantly, it empowers them with greater transparency and control." Rethinking Cost Sharing in a Price-Sensitive Era Cost sharing remains the most visible and impactful element of pharmacy benefit design for members. According to the report, 70% of payers are contemplating changes to their cost sharing structures, with many exploring increases in copays, coinsurance, or deductibles. To help members manage their cost sharing, over half of payers promote cost-sharing transparency tools, although views are mixed on the effectiveness and value of these tools. Employers Grapple with Fiduciary Risk and Future Investment Many benefits leaders are concerned about exposure to fiduciary risk through pharmacy benefits and are taking steps to protect themselves. One in three employers report making moderate or large changes to their approach to fiduciary responsibility in light of recent lawsuits alleging mismanagement of pharmacy benefits. "Employers are more alert than ever to the legal and financial responsibilities tied to benefit partnerships and decisions," said Mike Medel, Senior Vice President and Practice Lead, Plan Sponsors at PSG. "We're seeing employers invest more time in vendor selection, pricing models, and governance processes because they know the risks of fiduciary criticism are real and growing." The report also reveals that half of employers expect to increase their investment in benefits over the next one to two years, with pharmacy benefits ranking among the top three targeted areas for expansion. Read all the insights in the full report available here. About the 2025 Trends in Drug Benefit Design Report The Trends in Drug Benefit Design Report provides in-depth insights into traditional (non-specialty) drug benefit trends and strategies and focuses on drug benefit design for the 2025 benefit year among employers, union/Taft-Hartley, and health plan respondents. The survey sample informing this report included 222 benefits leaders. Issues specific to specialty drugs are included in a separate report — Trends in Specialty Drug Benefits. This report, as well as prior annual reports conducted by PSG, can be found at About Pharmaceutical Strategies Group (PSG) Pharmaceutical Strategies Group, an EPIC company, relentlessly advocates for clients as they navigate complex and ever-changing drug cost management challenges. PSG is an independent consultant, empowering healthcare payers to manage their pharmacy program better. As a strategic partner, PSG helps clients by providing industry-leading intelligence and technologies to realize billions of dollars in drug cost savings for clients every year. View source version on Contacts Media Contact Gregory FCA for PSGEPIC@ Sign in to access your portfolio
Business Wire
2 days ago
- Business
- Business Wire
PSG Releases 2025 Drug Benefit Design Report: PBM Unbundling Gains Momentum and Payers Navigate GLP-1 Coverage Decisions Amid Rising Costs
DALLAS--(BUSINESS WIRE)--Pharmaceutical Strategies Group (' PSG '), an EPIC company Trends in Drug Benefit Design Report, delivering critical insights into how payers are navigating a rapidly evolving pharmacy benefits landscape. For three decades, this industry report has been an essential resource for employers, health plans, and other stakeholders seeking to understand and adapt to changes in pharmacy benefit design and management. The 2025 edition addresses both foundational benefit design elements — including formulary and network design, utilization management, and cost sharing — and today's most pressing challenges, such as GLP-1 coverage decisions, heightened fiduciary liability concerns, and the accelerating shift toward unbundled PBM arrangements. Drawing from extensive research and insights from benefits leaders nationwide, the report provides actionable intelligence for organizations working to balance member access and affordability with effective pharmacy spend control. Read all the insights in the full report available here. Navigating the GLP-1 Surge While nearly all plans cover GLP-1s for type 2 diabetes (92%), only 39% currently cover GLP-1s for obesity. Cost is a large concern for payers with respect to GLP-1s for obesity, but even so, the survey finds that nearly half of plans that currently exclude these drugs from coverage say they would not cover the drugs at any price. Benefits leaders must balance the overwhelming demand for these medications with their cost as well as the decision to cover a treatment for obesity. 'GLP-1s are the area of this report where we see the most variation in perception and strategy,' said Morgan Lee, Senior Director of Research & Strategy at PSG. 'Respondents are very concerned about GLP-1 affordability for the plan, and many are concerned about off-label use of GLP-1s for type 2 diabetes, yet nearly half don't know how much of their current spending is for off-label purposes. We're also seeing continued variation in how plans perceive GLP-1s for obesity, whether as lifestyle drugs or as treatments for a chronic disease. As the GLP-1 landscape rapidly evolves with expanded indications, direct-to-consumer offerings, and more, payers will continue to have new considerations and decisions to navigate.' Unbundling Pharmacy Benefit Management One of the most disruptive strategies explored in the report is the shift toward unbundling PBM services. This year's report revealed that a growing number of payers are evaluating or already pursuing this modular approach, which allows organizations to separate functions, such as claims processing, formulary management, and rebate negotiation, and contract them independently. 'We're seeing rising interest in partial or fully modular PBM arrangements,' shared Beth Hebert-Silvia, Senior Vice President, Health Plans Practice Leader at PSG. 'This strategy isn't plug-and-play. It requires sophisticated design and execution, but it enables plans to align each element of their pharmacy benefit with their unique needs. More importantly, it empowers them with greater transparency and control.' Rethinking Cost Sharing in a Price-Sensitive Era Cost sharing remains the most visible and impactful element of pharmacy benefit design for members. According to the report, 70% of payers are contemplating changes to their cost sharing structures, with many exploring increases in copays, coinsurance, or deductibles. To help members manage their cost sharing, over half of payers promote cost-sharing transparency tools, although views are mixed on the effectiveness and value of these tools. Employers Grapple with Fiduciary Risk and Future Investment Many benefits leaders are concerned about exposure to fiduciary risk through pharmacy benefits and are taking steps to protect themselves. One in three employers report making moderate or large changes to their approach to fiduciary responsibility in light of recent lawsuits alleging mismanagement of pharmacy benefits. 'Employers are more alert than ever to the legal and financial responsibilities tied to benefit partnerships and decisions,' said Mike Medel, Senior Vice President and Practice Lead, Plan Sponsors at PSG. 'We're seeing employers invest more time in vendor selection, pricing models, and governance processes because they know the risks of fiduciary criticism are real and growing.' The report also reveals that half of employers expect to increase their investment in benefits over the next one to two years, with pharmacy benefits ranking among the top three targeted areas for expansion. Read all the insights in the full report available here. About the 2025 Trends in Drug Benefit Design Report The Trends in Drug Benefit Design Report provides in-depth insights into traditional (non-specialty) drug benefit trends and strategies and focuses on drug benefit design for the 2025 benefit year among employers, union/Taft-Hartley, and health plan respondents. The survey sample informing this report included 222 benefits leaders. Issues specific to specialty drugs are included in a separate report — Trends in Specialty Drug Benefits. This report, as well as prior annual reports conducted by PSG, can be found at Pharmaceutical Strategies Group, an EPIC company, relentlessly advocates for clients as they navigate complex and ever-changing drug cost management challenges. PSG is an independent consultant, empowering healthcare payers to manage their pharmacy program better. As a strategic partner, PSG helps clients by providing industry-leading intelligence and technologies to realize billions of dollars in drug cost savings for clients every year.
Forbes
28-04-2025
- Health
- Forbes
Health Plans Brace For Cell And Gene Therapy Costs
Cell and gene therapies are breaking ground as life-saving treatments, but their six- and seven-figure price tags are an increasing worry for employers and healths, according to a new analysis. More than 70% of employers and health plans expect affordability of gene therapy for their health plan members and workers will be a 'moderate or major challenge' over the next 2 to 3 years, according to a report released Monday at Asembia ASX25 in Las Vegas by Pharmaceutical Strategies Group (PSG). The analysis was based on responses from more than 230 health benefits executives from health plans, employers and unions. The report comes with up to a dozen new cell and gene therapies expected to launch on the U.S. market this year, PSG's report said. Such therapies, which can 'prevent or treat a disease by adding, replacing, or turning off genes,' come with high prices such as $475,000 for a treatment for acute lymphoblastic leukemia or more than $3 million for a treatment for hemophilia B. Yet despite the headline-grabbing costs of some of these new treatments, those picking up the tab for the bulk of the costs aren't prepared for potential expenses to their budgets for healthcare. Even though 73% of plans expect cell and gene therapies to 'pose a moderate or major financial challenge in the next 2–3 years, most express low confidence in their understanding of the financial impact,' PSG said in a statement accompanying its report. 'What's more, nearly 40% don't currently use any financial protection product to manage their financial risk related to cell and gene therapies.' 'These therapies aren't one-size-fits-all,' said Renee Rayburg, vice president of clinical strategy at PSG. 'Not only do gene therapies present financial challenges, they're also complex in terms of which patients are eligible as well as the treatment process, and demand is higher for some gene therapies than others. Payers need expert analysis that considers their population, pipeline exposure, and vendor ecosystem.' Specialty drugs already account for well more than half of the total prescription spending any health plan, employer or government health program manages. Employer clients tell benefits consultants specialty costs easily account for 60% or more of their total drug spending, particularly as more Americans flock to anti-obesity GLP-1 medicines, prescriptions hailed for their ability to help people lose weight. But the PSG report says employers are increasingly finding ways to deal with specialty drugs. Take Humira, for example, an expensive rheumatoid arthritis drug derived from biotechnology that at its peak generated more than $20 billion in annual sales as the world's top selling drug for its maker, Abbvie. Humira costs more than $50,00o a patient. But increasingly health plans and employers are covering less expensive biosimilar versions of Humira in a 'preferred position' in their preferred list of drugs known as formularies. The PSG report said '65% of plans have implemented a preferred drug strategy for one or more Humira biosimilars.' 'Leaders are eager to try new approaches to address costs while preserving access to drugs that their members need,' said PSG's chief operating officer, Rebekah Gregg. 'Yet many benefit leaders lack the data, infrastructure, and confidence to fully implement those strategies. Transparency and clear, data- driven insights will be vital to adapt to the pressures payers face.'
