On The Radar – 25th Edition
By
After years of operating behind the scenes, the PBM industry’s largest lobbying group has launched its biggest public relations campaign ever. The effort comes as federal reforms increase transparency requirements and lawmakers continue pushing for additional oversight.
➡ Why it matters: The conversation around prescription drug costs is shifting from who to blame toward who controls the dollars flowing through the system.
Some experts argue that the biggest contributor to healthcare spending isn’t the price of care itself, but the administrative maze surrounding it. Multiple layers of insurers, TPAs, PBMs, and intermediaries add significant overhead before care ever reaches the patient.
➡ Why it matters: Employers are increasingly exploring direct-pay and simplified care models to reduce friction and administrative waste.
Facing a $300 billion patent cliff, pharmaceutical companies are ramping up acquisitions to refill pipelines and secure future growth. Successful GLP-1 manufacturers are using record profits to fund the next generation of therapies.
➡ Why it matters: The future of pharmaceutical innovation may depend as much on acquisitions as internal R&D.
Employers are rapidly rethinking pharmacy strategies as GLP-1 therapies consume a growing share of pharmacy spend. Many organizations are moving away from bundled pharmacy arrangements in favor of independent clinical management and utilization oversight.
➡Why it matters: Employers are no longer debating whether GLP-1s matter. They’re determining how to manage them sustainably.
Advocates continue to point to patent protections, lobbying influence, and delayed generic competition as major contributors to high prescription drug costs in the U.S. The pressure for reform continues to build across the political spectrum.
➡Why it matters: Drug affordability remains one of the few healthcare issues drawing broad bipartisan attention.
Experts caution that ERISA was designed to improve fiduciary oversight and transparency, not directly regulate healthcare prices. Still, its influence over vendor accountability and plan governance continues to grow.
➡Why it matters: Employers are being asked to play a larger role in managing healthcare costs without necessarily being given new pricing tools.
State legislatures continue advancing PBM reform efforts focused on transparency, pharmacy reimbursement, and anti-steering provisions. The result is an increasingly complex patchwork of regulations across the country.
➡ Why it matters: PBM reform is no longer a federal conversation alone. States are becoming major drivers of change.
U.S. healthcare spending climbed to $5.7 trillion in 2025 and is projected to exceed $9 trillion by 2034. Prescription drugs and an aging population continue to be major contributors to this growth.
➡ Why it matters: Healthcare costs are growing faster than the broader economy, increasing pressure on employers, public programs, and families.
While GLP-1 therapies offer meaningful clinical benefits, employers remain cautious about long-term financial sustainability. Many are implementing tighter clinical criteria and prior authorization strategies rather than broad open access.
➡ Why it matters: Coverage decisions increasingly hinge on demonstrating measurable long-term value, not simply demand.
Prescription drug spending is expected to surpass $1 trillion for the first time, fueled largely by specialty medications and GLP-1 therapies. At the same time, traditional drug price inflation has slowed considerably.
➡ Why it matters: The challenge is shifting from rising prices alone to managing utilization, access, and long-term affordability.
Final Thoughts
Healthcare’s cost challenges are becoming less about any single stakeholder and more about how the entire system is structured. Employers are demanding transparency, policymakers are increasing scrutiny, and the traditional pharmacy supply chain is facing pressure from every direction. The organizations best positioned for the future may be those willing to rethink how healthcare is purchased, managed, and delivered.
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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