Ken Rose
Regional Director, National Pharmacy Practice / Marsh Rx Solutions
Your pharmacy program often makes up the largest share of your healthcare costs, according to a 2025 AHIP study.1 Here are a few things to consider to help keep that program effective and affordable.
Costs are rising as new treatments and therapies become available. PwC reported that pharmacy cost trends in 2025 were 2.5 percentage points higher than medical cost trends.2 Oncology, immunology, and obesity treatments are major drivers of that spending; some estimates put cancer treatments at about half of specialty drug costs.3
A UnitedHealthcare analysis found specialty drugs make up roughly 2% of pharmacy volume but about 60% of pharmacy spending.4 CarelonRx reports the specialty drug market grew from $92.5 billion in 2023 to nearly $130 billion in 2024 and could reach $965.5 billion by 2030.5 Many employers are testing new contract terms and payment approaches to manage rising costs while maintaining employee access to these often costly treatments.
Which PBM model makes sense for you?
Most Pharmacy Benefit Managers (PBMs) operate under one of three models:
- Value-driven formulary model: The formulary focuses on total value and lowest net cost rather than maximizing rebates.
- Utilization-management model: Clinical oversight guides use so members get the right drug at the right time for the right reason.
- Alternative-access model: Uses strategies such as patient-assistance programs, international sourcing, or 340B pricing to lower overall spend.*
Once you choose a primary PBM approach (value-driven, utilization-management, or a blend), you can layer alternative access strategies selectively. Keep in mind that these strategies may not deliver expected savings unless the PBM and the plan design are a good fit.
Three trends that can directly affect your pharmacy program
1. Biosimilars and advanced therapies
The FDA defines biosimilars as highly similar, FDA-approved alternatives to original biologic drugs that can offer the same safety and effectiveness at potentially lower cost.
Review your PBM contract to see whether it supports a “biosimilar strategy” (biosimilars available but not prioritized) or a “biosimilar-first” approach (patients start on the lower-cost biosimilar before the branded therapy). The difference affects costs and patient pathways.
2. Cell and gene therapies (CGT)
CGT can treat — and in some cases may cure — serious conditions such as sickle cell disease and hemophilia. They are also among the highest‑cost treatments. EBRI reports use of CGT in employer plans was still rare in 2022 (about 9.2 per 100,000) but is rising, which could increase plan financial exposure as more approvals occur.6
3. GLP-1 treatments
GLP-1 medications, often used for diabetes and increasingly for weight loss, are one of the fastest-growing categories in pharmacy. They’re also being used off-label for conditions like sleep apnea, non-alcoholic fatty liver disease, and substance use disorders.7
Coverage considerations:
- Cost — Estimated average annual cost per patient is around $6,000.8 Expect steep year-over-year cost trends for groups that cover these drugs.
- Sustainability — Some studies show patients regain a large share of weight after stopping GLP-1s; combining medication with a lifestyle program and a plan for de-prescribing can improve long-term outcomes.9
- Discontinuation — Analyses show adherence and persistence drop significantly after one year in many populations, which affects clinical and financial planning.10
- Employee interest — Surveys indicate a substantial portion of employees want weight-loss drugs included in benefits.11
PBM legislation, contracts, and transparency
In 2025, states introduced many PBM-related bills and tracking shows widespread legislative activity on drug pricing and PBM practices.12 Regardless of legal outcomes, PBM contracts vary in how they manage utilization, negotiate pricing, and structure formularies. Each contract approach has trade-offs and should be compared against alternatives to find the best fit for your plan.
How MMA can help
Marsh McLennan Agency (MMA) can help you evaluate benefit design and stop‑loss coverage; prepare for GLP-1 coverage; assess PBM contracts and transparency; and test whether biosimilars or tiered management could lower costs. We can also help optimize PBM contracts before you pursue alternative access strategies. Contact us to learn more.
For additional information, view our recent webinar, Innovative Strategies to Contain Healthcare Costs While Enhancing Employee Benefits.
*Strategies such as international sourcing or 340B pricing involve legal and regulatory considerations and should be reviewed by legal counsel or compliance teams.
Sources
1 AHIP. “Where Does Your Health Care Dollar Go?”
2 PwC Health Research. “Behind the Numbers.”
3 “Springbuk. “Employee Health Trends 2025.” (gated)
4 UnitedHealthcare. “Prioritizing Pharmacy: Care Costs and Strategies.”
5 CarelonRx. “Specialty Drug Growth.”
9 PubMed Central. Peer-reviewed study on weight regain after GLP-1 discontinuation.
10 The American Journal of Managed Care (AJMC). “GLP-1 RA adherence shows drop-off after 1 year.”
11 Tebra. “Weighing In on Employee Benefits: Employees demand weight-loss coverage.”
12 NASHP. “2025 State Legislation to Lower Prescription Drug Costs.”
