On The Radar – 9th Edition
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As federal action lags, employers are taking control. Many are auditing PBM contracts, uncovering hidden spread pricing and retained rebates, and partnering with transparent pharmacy administrators that offer 100 percent pass-through models and full claims visibility.
➡ Why it matters: Employers no longer need to wait for legislation to reduce spend and regain control over pharmacy costs.
A new agreement between the Trump administration and Eli Lilly and Novo Nordisk will lower GLP-1 prices and expand coverage through Medicare and TrumpRx.gov. Oral versions may cost as little as $149 per month beginning in 2026.
➡ Why it matters: Treating obesity as a chronic condition is gaining traction, but affordability and utilization management remain critical.
The FDA is facing scrutiny for approving drugs that fail confirmatory trials under the accelerated approval pathway. Critics warn that the trend could undermine scientific rigor and inflate costs for unproven treatments.
➡ Why it matters: Employers and plan sponsors need to stay alert to ensure plan formularies prioritize proven, cost-effective therapies.
Rare disease and oncology treatments dominate the pipeline, self-administered drugs are on the rise, and biosimilars are multiplying rapidly. With over 40 biosimilars launching by 2027, PBMs will play a pivotal role in determining market access.
➡ Why it matters: Specialty spend is not slowing down, and plan strategies must evolve to capture biosimilar opportunities.
High-deductible health plans now cover 58 percent of the workforce but have pushed significant costs onto employees. Innovative employers are adopting flexible financing models that cover upfront expenses and offer zero-interest repayment options.
➡ Why it matters: Reducing the financial shock of healthcare can improve employee well-being and long-term outcomes.
Healthcare costs are rising faster than ever, driven by chronic conditions and GLP-1 drugs. Experts advise treating obesity as a chronic disease and combining medication with behavioral change programs to improve outcomes and manage costs.
➡ Why it matters: A whole-health approach is the only sustainable path to balancing employee well-being and organizational cost control.
A coalition of employers, advocacy groups, and health organizations is urging lawmakers to pass PBM reform that bans spread pricing, enforces 100 percent rebate pass-through, and delinks PBM compensation from drug prices.
➡ Why it matters: The push for accountability is bipartisan, and employer advocacy is driving momentum.
Rising million-dollar claims, expensive specialty drugs, and provider inflation are pushing employer costs to record highs. Employers are encouraged to adopt bill review services, specialty carve-outs, and data-driven management programs.
➡ Why it matters: The right cost-containment strategies can reduce claims without reducing care quality.
Three vertically integrated PBMs control over 80 percent of the market. The article calls for legislative action and employer-led changes to procurement practices to increase transparency and competition.
➡ Why it matters: True reform depends on breaking up vertical integration and shifting market leverage back to plan sponsors.
Final Thoughts
Employers and lawmakers are taking bold steps to restore transparency and accountability across the healthcare system. As the cost pressures from GLP-1s, specialty drugs, and high deductibles continue, those who act early—by auditing PBMs, rethinking plan design, and prioritizing member health—will lead the way in sustainable cost containment.
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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