On The Radar
By
Patients are often paying more than necessary. Experts recommend comparison shopping, leveraging generics, manufacturer programs, and 90-day prescriptions—all while understanding insurance terms.
➡ Why it matters: Even insured members may face unnecessary costs. Education and navigation can have an outsized impact.
A $5B Loophole That Hurts Patients
Insurers and PBMs exploit the “EHB loophole” to seize copay assistance funds, leaving patients with massive out-of-pocket bills. Protections exist for individual plans, but most employer-based coverage remains vulnerable.
➡ Why it matters: Until federal rules close this loophole, plan sponsors must be vigilant about PBM practices that drive hidden costs.
Pharma Reclaims the Patient Experience
Drugmakers are moving away from outdated third-party hubs, using AI and automation to manage patient support programs directly. Hybrid models are emerging, blending tech with human connection.
➡ Why it matters: Better patient support can improve adherence—but raises questions about transparency, data ownership, and costs.
Drug Patents: Innovation vs. Affordability
Patents incentivize R&D but also drive “evergreening” and delay generics. Biologics face even more complex patent disputes, slowing biosimilar entry.
➡ Why it matters: Patent cliffs often mark major cost turning points for employers—and opportunities for spend reduction.
Facing threats like price negotiations and ad restrictions, pharma is ramping up political influence. Despite pushback, it secured wins such as expanded orphan drug exemptions in the OBBB Act.
➡ Why it matters: Lobbying spend is shaping policy outcomes that directly affect employer pharmacy budgets.
PBMs Go on the Offensive
PBM trade group PCMA is backing bipartisan bills to curb patent abuse and boost generics and biosimilars. They cite broad public support for stopping manufacturer tactics that block competition.
➡ Why it matters: Employers should track whether PBM-backed reforms improve costs—or simply protect PBM interests.
Rising Healthcare Costs Strain Families
Families are cutting spending, taking on debt, and delaying goals due to higher premiums and drug costs.
➡ Why it matters: Financial stress from healthcare trickles into workforce productivity, retention, and absenteeism.
Employers Turn to Preventive Drug Lists
PDLs reduce or eliminate out-of-pocket costs for drugs treating chronic conditions, improving adherence and lowering long-term spend.
➡ Why it matters: PDLs are a practical way for self-funded employers to drive both cost control and member health.
Stop-Loss Coverage on the Rise
74% of self-insured plans now carry stop-loss insurance, up sharply in one year—especially among mid-sized employers.
➡ Why it matters: As drug claims spike, stop-loss has become a critical safety net.
Pharma’s New Watchdog: IRA Under Attack
Major drugmakers formed IRA Watchdog to oppose expanded Medicare drug price negotiations. Critics call it a front to delay cost-reduction measures.
➡ Why it matters: The industry is mobilizing aggressively against government efforts to curb drug prices.
Insiders Speak Out on Generic Drug Quality
Whistleblowers raise concerns about contamination, overseas manufacturing, and misleading advertising.
➡ Why it matters: Generics are essential for cost reduction, but quality oversight is critical for safety and trust.
Rising Drug Costs Threaten Benefits
Specialty and GLP-1 drugs now dominate pharmacy budgets. Experts recommend pharmacy carve-outs, biosimilar promotion, and innovative transparency models.
➡ Why it matters: Without action, drug costs will overwhelm employer health benefits.
Final Thoughts
Across every level—from households to employers to Capitol Hill—drug pricing is the central pressure point. Employers and brokers who adopt proactive strategies will be best positioned to protect both financial health and member well-being.
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!
Stay Connected with SHARx
Subscribe to our newsletter for monthly updates from our CEO, curated industry news, insights from our in-house pharmacist, the latest blog posts, and more. Just fill out the form to stay informed.
Newsletter Sign-up
Be the first to learn what’s new with SHARx.