On The Radar – 23rd Edition
By
Three major health systems have sued CVS, alleging the company improperly retained millions in savings generated through the federal 340B Drug Pricing Program instead of passing those funds back to hospitals serving vulnerable patient populations.
➡ Why it matters: The case adds fuel to ongoing debates around transparency, accountability, and who ultimately benefits from healthcare discounts.
A growing number of policymakers are calling for stronger 340B oversight and comprehensive PBM reform, including spread pricing bans and 100% rebate pass-through requirements.
➡ Why it matters: Both proposals focus on ensuring healthcare savings reach patients and plan sponsors rather than intermediaries.
Critics argue that prior authorization requirements and claim denials continue delaying treatment and increasing administrative burdens for providers and patients alike.
➡ Why it matters: Transparency around care denials is becoming a major healthcare policy and affordability issue.
New data-driven PBM models are providing employers with deeper visibility into drug pricing, rebates, utilization patterns, and specialty medication spend.
➡Why it matters: Better data is helping employers make more informed decisions and control pharmacy costs more effectively.
As specialty medications consume a growing share of healthcare budgets, employers are implementing tighter clinical oversight and more sophisticated pharmacy management programs.
➡Why it matters: Specialty drug spend remains one of the fastest-growing challenges facing self-funded health plans.
Industry critics continue arguing that brand-name manufacturers use patent protections and pricing strategies to maintain high drug costs and limit generic competition.
➡Why it matters: The debate over who bears responsibility for rising prescription costs remains central to healthcare reform efforts.
While GLP-1s dominate headlines today, employers are preparing for a future wave of gene and cell therapies that can cost millions per treatment.
➡ Why it matters: The next generation of breakthrough therapies may require entirely new approaches to risk management and benefit design.
A new report found that the top-selling brand-name drugs increased in price by an average of 81% after entering the U.S. market, while prices often declined in other developed countries.
➡ Why it matters: Rising drug prices continue placing pressure on employer-sponsored health plans and overall healthcare affordability.
The U.S. generic drug market is expected to exceed $130 billion by 2034 as patent expirations create new opportunities for lower-cost alternatives.
➡ Why it matters: Generics remain one of the most important tools for expanding access while controlling healthcare costs.
Industry experts point to GLP-1 growth, PBM transparency regulations, alternative pharmacy sourcing channels, unbundled services, and rising employee cost-sharing as key trends shaping the market.
➡ Why it matters: The pharmacy landscape is evolving quickly, forcing employers to rethink traditional benefit strategies.
Employer healthcare costs are projected to rise 7.9% in 2026, with prescription drug spending increasing nearly 15% as GLP-1 utilization continues to grow.
➡ Why it matters: Employers face mounting pressure to balance affordability, access, and long-term sustainability.
Final Thoughts
Healthcare affordability remains under pressure from every direction. Between rising specialty drug costs, increasing scrutiny of PBMs and 340B programs, and the growing impact of GLP-1s and gene therapies, employers are being forced to take a more active role in managing pharmacy benefits and controlling healthcare spend.
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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