On The Radar – 3rd Edition
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Arkansas attempted to ban the Big Three PBMs from owning pharmacies—blocked temporarily in court—while 15 states consider similar measures. Federally, the FTC filed lawsuits against PBMs, and President Trump demanded manufacturers cut GLP-1 prices. Employers aren’t waiting either: 34% are evaluating new PBM entrants to improve transparency.
➡ Why it matters: Expect more disruption in PBM contracting as states, the feds, and employers push for accountability.
Bipartisan Push to Break Patent Barriers
The ETHIC Act, backed by Senators Welch, Hawley, and Klobuchar, seeks to limit the number of patents tied to new drugs, curbing “patent thickets” that delay generics and inflate prices.
➡ Why it matters: Greater competition could speed access to generics and directly reduce prescription drug costs.
AMA Calls for PBM Oversight
The AMA highlights how vertical integration and market consolidation drive up premiums and squeeze pharmacies. Their advocacy campaigns and support for the PBM Reform Act of 2025 aim to bring transparency to the system.
➡ Why it matters: When physician groups amplify calls for reform, it increases political momentum for change.
Finding the Balance: AI + Human Touch
AI is making prior authorizations and claims more efficient—but physicians warn of risks if human oversight is reduced. The best approach blends AI for efficiency with people-centered care.
➡ Why it matters: Employers should vet PBM partners carefully to ensure tech enhances—not replaces—quality care.
At an FTC session, GOP advisers criticized rebate-driven incentives that favor costly drugs and flagged patent thickets as barriers to generics. The PBM Transparency Act and the Medication Affordability and Patent Integrity Act were cited as potential solutions.
➡ Why it matters: Reform proposals are expanding beyond PBMs to tackle drug manufacturer practices as well.
The “One Big Beautiful Bill Act” Draws Fire
The OBBB mixes reforms—banning PBM spread pricing in Medicaid and offering tax incentives for onshoring—with controversial rollbacks of Medicare negotiation powers. Critics warn it could raise out-of-pocket costs for seniors while boosting pharma profits.
➡ Why it matters: Even “reform” bills often have trade-offs that complicate benefit planning.
New Hope for Multiple Myeloma
The FDA granted orphan designation to Sanofi’s monoclonal antibody for relapsed/refractory multiple myeloma, now in Phase 1 trials.
➡ Why it matters: Pipeline innovation continues, but affordability and access remain looming questions.
Specialty Drug Costs Rise, But Trend Slows
Specialty costs per member rose from $1,333 in 2023 to $1,641 in 2024. But overall growth slowed to 9.6%, thanks to biosimilar adoption—particularly for Humira.
➡ Why it matters: Biosimilars are finally bending the cost curve. Faster adoption could ease pressure on employer budgets.
AMA Warns: PBM Power Puts Patients at Risk
AMA President Bobby Mukkamala criticized the Big Four PBMs’ dominance (67% market share), warning that vertical integration reduces patient choice and transparency. The group backs the PBM Reform Act of 2025 to address these risks.
➡ Why it matters: The push for PBM accountability is gaining credibility from physician leadership.
Final Thoughts
From PBM lawsuits to patent reform bills, the landscape of drug pricing is shifting rapidly. Employers and brokers should track these changes closely and demand transparent, high-value partnerships to protect both budgets and members.
We’ll be back in two weeks with more news you need to know. If you’d like a custom analysis or want to explore SHARx program options for your clients, contact us!
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