On The Radar – 13th Edition
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Humana’s CenterWell Pharmacy and Eli Lilly are rolling out a direct-to-employer GLP-1 distribution model designed to bypass traditional channels and reduce administrative friction. By using carve-outs managed by independent TPAs, employers gain more control over access, pricing, and program design for obesity treatments.
➡ Why it matters: Direct-to-employer drug models are no longer experimental. Employers are gaining new options to manage high-cost therapies without fully relying on traditional PBM structures.
This opinion piece argues that PBM consolidation is actively blocking lower-cost biosimilars from reaching patients. With three PBMs controlling most of the market, the author points to anticompetitive practices that inflate prices and limit access, despite mounting regulatory scrutiny.
➡ Why it matters: PBM reform is increasingly tied to specialty drug affordability. Without structural change, biosimilars may not deliver the financial impact employers are expecting.
A compounding pharmacy has filed an antitrust lawsuit alleging Eli Lilly and Novo Nordisk used exclusivity agreements to suppress access to lower-cost, customized GLP-1 alternatives. The case highlights rising tension between Big Pharma and compounders that filled gaps during recent shortages.
➡ Why it matters: Legal challenges could influence how employers, providers, and patients navigate GLP-1 access when branded options remain costly or restricted.
Drugmakers are accelerating U.S.-based manufacturing investments in response to tariffs, supply chain risk, and pricing pressure. These moves aim to improve reliability, shorten regulatory timelines, and align with pricing agreements tied to domestic production.
➡ Why it matters: Onshoring may improve supply stability and pricing predictability, but it also signals how trade policy is reshaping pharmaceutical economics.
The administration’s proposed “Great Healthcare Plan” focuses on MFN drug pricing, expanded direct purchasing via TrumpRx, HSA-based subsidies, and plain-language price transparency across insurers, providers, and PBMs.
➡ Why it matters: If enacted, these proposals would significantly alter how prescription drugs are priced, purchased, and disclosed, with downstream effects for employer plans.
This explainer breaks down rebate mechanics, spread pricing, and vertical integration, showing how PBM structures can shift higher costs onto the sickest patients while obscuring true net pricing.
➡ Why it matters: Employers cannot manage pharmacy spend effectively without understanding where dollars flow and how incentives are structured.
A national PBM is launching a DTC option that allows patients to pay transparent, upfront prices without navigating insurance tiers, responding to demand from high-deductible and cash-pay consumers.
➡ Why it matters: PBMs adopting DTC models reflects growing pressure for transparency and may change how benefits interact with cash-pay channels.
Albertsons has sued Express Scripts over alleged claim “downcoding” that reduced pharmacy reimbursement while patients paid brand prices. The dispute highlights ongoing friction over claim adjudication practices.
➡ Why it matters: Legal scrutiny of PBM claim practices raises questions about fairness, pharmacy sustainability, and patient access.
Often marketed as predictable and low-risk, level-funded plans may expose employers to hidden liabilities, including retained pharmacy revenue, stop-loss exclusions, ERISA fiduciary risk, and liquidity strain during large claims.
➡ Why it matters: Employers may be assuming more risk than they realize, making transparency and contract review essential.
Direct-to-employer and direct-to-consumer drug models are expanding alongside PBMs, offering fixed pricing for specialty drugs but creating new data and governance challenges.
➡ Why it matters: As pharmacy access becomes more fragmented, employers must reassess contracts, data visibility, and fiduciary documentation.
This opinion argues that patent “thickets,” not pricing negotiations alone, are the biggest barrier to lower drug costs. Delayed biosimilar entry keeps prices elevated long after patents should expire.
➡ Why it matters: Patent policy plays a critical role in specialty drug affordability and long-term cost containment.
Proposed legislation would classify PBMs as ERISA fiduciaries, forcing full compensation disclosure and alignment with plan interests. While transparency would improve, oversight responsibilities for employers would increase.
➡ Why it matters: Even with PBMs designated as fiduciaries, employers retain monitoring obligations, raising the stakes for governance and compliance.
Final Thoughts
As GLP-1 strategies evolve and transparency moves from “nice to have” to non-negotiable, the line between policy, pricing, and plan design keeps blurring. The takeaway is clear: waiting on reform is no longer a strategy. Employers and brokers who understand what’s shifting now will be better positioned to manage cost, risk, and access moving forward.
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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