Don’t have 45 minutes for on-demand insights from frontline RxSS Roundtable experts ? We captured the webinar highlights and takeaways for a quick read. Learn how the panel weighed in on key issues for payers and patients in 2025—from a political, clinical and practical perspective.
[Views expressed by the panelists are based on analysis of information available in late December 2024.]
Impact of the 2024 Election and the Latest from Capitol Hill
Jennifer Wagner, Director of Public and Government Affairs, opened with her take on:
President Donald Trump and the 119th Congress
Expect a busy first 2 years on Trump’s tax, energy and border protection promises, but healthcare will get plenty of time in the sun. Wagner anticipates an overall climate of innovation, economic growth and deregulation. We may, however, see increased regulatory emphasis on consumer protections with respect to data privacy and price transparency.
Drug prices, PBMs, and the IRA
It will be interesting to see how Trump’s pro-business stance meshes with previous and current rhetoric against high drug prices and pharma.
Drug makers are already pressuring the incoming administration to delay the timeline for Medicare drug price negotiations, a key provision of the Inflation Reduction Act (IRA). While Congress and the Administration may be more inclined to tweak this component of the law, the IRA’s Part D redesign and $2,000 OOP cap are unlikely to go anywhere. Complete repeal of the IRA doesn’t appear to be a goal, but adjustments or delayed implementation are not out of the question for the Trump team and GOP majority.
PBMs are sure to remain in the reform crosshairs, with continued scrutiny from Congress and the Administration as well as state legislators. State policy trends focused on reining in drug costs will also carry on, particularly through continued implementation of prescription drug affordability boards.
Medicare, Part D, and Consumer Empowerment Tools
Despite new financial and operational pressures weighing heavily on Medicare Part D sponsors today, Medicare Advantage may see better days ahead. Incoming CMS administrator Mehmet Cengiz Öz (“Dr. Oz”) is a big Medicare Advantage champion. We can likely expect to see stronger support for MA and a boost to payment rates.
Lastly, along with cost transparency, Washington’s bipartisan appetite for consumer- and patient-centered chronic disease management and prevention tools continues to grow.
GLP-1 Trends
Mercer employer survey
Mercer’s 2024 National Survey of Employer-sponsored Health Plans found pharmacy benefit costs climbed by nearly 8% in 2024, after an 8% climb last year, largely driven by covering GLP-1 drugs for diabetes and obesity.*
Lawmakers and regulators taking note
A new rule proposed recently by CMS basically reinterprets the statutory exclusion of weight loss drug coverage by Medicare and Medicaid. If finalized, coverage for anti-obesity medications could really set the tone for the rest of the market. It’s up to the new administration to decide.
Observations of the Market, Payers and Patients Over the Past Year
Bryan Schuessler, PharmD, MS, CSP, Director of Product Management, and Shelby Luzenske, PharmD, Director of Pharmacy, weighed in on:
Member demand vs. plan coverage
About 80% of members/patients expect GLP-1s to be covered by their insurance. The Mercer survey showed more employers covering GLP-1s for obesity in 2025—about 46%, with 21% more considering within the next 3 years.*
Schuessler estimates that 10%-15% more RxSS clients cover the drugs for obesity than last year. However, an equivalent number have implemented more structure and program requirements, including traditional utilization management but also NPI restriction and mandatory lifestyle management programs.
Shortages and compounding questions
Despite more products and fulfillment channels in the market, access can be subject to shortages. Whether due to shortages or cost, more are turning to compounding pharmacies and compounded GLP-1 products, which has raised some reliability and consistency issues.
Treatment challenges and product preference
Blue Health Intelligence reports that roughly 50% of patients on GLP-1s stop treatment within 12 weeks due to insufficient dose management, side effects (especially GI issues) or cost. Nevertheless, RxSS portal searches continue to trend upward.**
For RxSS clients that cover the medications under the pharmacy benefit, GLP-1 claims have increased in the past 6 months, particularly for more recent market entrants, perhaps due to shortages from increased utilization of established brands***:
- Zepbound claims up 80-90% vs. Wegovy 10-15%
- Mounjaro up 25% vs. Ozempic (mostly flat)
Managing Specialty Costs, Maintaining Patient Access
Brittany Ulrich, PharmD, CSP, Specialty Pharmacist – Sales, touched on the evolving specialty market and the growing impact of biosimilars.
Fresh hopes for cost relief
Lower-cost alternatives for expensive specialty drugs used to be rare. That’s changing thanks to a combination of market growth, patent expirations, and the evolution of biosimilars. Lawmakers and regulators generally support making these drugs more accessible to patients.
Six Stelara biosimilars are scheduled for release in 2025; one has already been given interchangeability status. Early signs point to major PBMs taking a similar approach to Humira biosimilars, where the plan-selected biosimilar will be on formulary at parity. Ulrich believes that within 6-12 months plans will either completely remove Stelara from formulary or prefer a biosimilar at a lower tier.
Actemra and Eylea also have recent biosimilar releases. Conversions have been light to date, but Ulrich expects that to change in 2025.
Sooner the better
Despite a common misconception that savings opportunity is limited with specialty medications, roughly 25% of the ~60,000 suggestions in the RxSS clinical engine apply to specialty drugs. Specialty strategies should focus on conversion to generics and biosimilars soon after they hit the market to maximize savings from the significant cost differences vs. brand products.
This can be easier with generics, which are often automatically substituted at the counter. However, not every pharmacy or system updates its “auto-sub” data for generics, so patient awareness of and education about their real-time options is critical.
Partnering with a vendor that can not only provide member outreach about new generics or biosimilars but assist with prescriber approval if needed is a great way to help reduce specialty spend.
* Mercer; 2024 National Survey of Employer-sponsored Health Plans, December 2024.
** Blue Cross Blue Shield; “Most Americans Do Not Use Weight-Loss Drugs Long Enough to See Meaningful Weight-Loss,” May 21, 2024.
*** RxSS internal data; claims ingested across book of business, May-November 2024.
This summary only scratches the surface of these and other trending topics. To get more details, nuance and context, click below to listen to the full webinar. It’s 45 minutes well spent.
