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Consultant Connections

2025 // ISSUE 2

Consultant Connections is a quarterly newsletter, specifically for employee benefit and health and welfare consultants, dedicated to providing details and data needed to help employer clients maintain high-quality care for their plan participants while keeping prescription drug and related health care costs sustainable.

2024 Drug Trends, Costs and Strategies

Alexis Sova, PharmD
Clinical Advisor

Key trends and cost management strategies

In 2024, plan sponsors faced significant challenges due to marketplace shifts, including the adoption of Humira biosimilars, rising demand and utilization of glucagon-like peptide-1 receptor agonists (GLP-1s) and escalating specialty drug costs. These trends persist in 2025 with expanded GLP-1 indications, pressure on PBMs to announce Stelara biosimilar adoption, the introduction of the Xolair, Prolia and Soliris biosimilars and ongoing emphasis on managing specialty drug spend.

Advancements and opportunities for GLP-1s

Employers Health’s 2024 book of business data show three of the top five most utilized drugs among plan sponsors were the GLP-1 medications Ozempic (semaglutide), Mounjaro (tirzepatide) and Wegovy (semaglutide). This class accounted for 17.6% of total gross cost in 2024, an increase of 3.9% in comparison to 2023. Growth within this class is multifactorial, including updated treatment guidelines placing GLP-1s as an additional first-line option for Type 2 diabetes, rising popularity on social media and the resolution of long-term shortages. Most pharmacy benefit plans cover GLP-1s for the treatment of diabetes in alignment with American Diabetes Association recommendations.1 Employers Health continues to recommend plan sponsors utilize clinical edits, confirming a diabetes diagnosis and/or a history of non-GLP-1 antidiabetic medications to prevent off-label utilization. Employers Health data found that by electing such edits, GLP-1 fill rates were reduced by approximately 22%, further limiting off-label utilization and generating millions of dollars in savings for plan sponsors across the book of business.

On the weight management side, more plan sponsors under the Employers Health book of business moved to exclude weight loss medications in 2024 (57%) compared to 2023 (50%). For plans opting in to coverage, the Employers Health clinical team recommends robust utilization management to minimize unnecessary increases in spend. Plan sponsors who covered weight loss medications, including open coverage and with prior authorizations (PAs), experienced a total gross cost per member per month (PMPM) of approximately $16 in 2024, with projections upwards of $37 PMPM by 2026. (See Figure 1)

FIGURE 1

Employers Health GLP-1 Custom Clinical Strategies

CLINICAL STRATEGY

Anti-obesity Employers Health Class 1


CRITERIA

BMI ≥ 30 OR BMI ≥ 27 kg/m2 with weight-related comorbid condition (hypertension, diabetes, hyperlipidemia, etc.) + 10% weight loss

CLINICAL STRATEGY

Anti-obesity Employers Health Class 2


CRITERIA

BMI ≥ 35 + 10% weight loss

CLINICAL STRATEGY

Anti-obesity Employers Health Class 3


CRITERIA

BMI ≥ 40 + 10% weight loss

Biosimilar adoption and outlook

While GLP-1s continue to gain momentum, the adoption of biosimilars has helped to stabilize overall drug spend. When Humira (adalimumab) biosimilars first launched in 2023, the market growth was slow and limited due to formularies placing the biosimilars at parity with the reference product. This resulted in limited provider/patient uptake. However, 2024 marked the much-anticipated growth of Humira biosimilars, particularly for formularies that moved to exclude Humira. An internal collective-wide analysis found that for Humira exclusionary formularies, over 90% of members switched to a preferred biosimilar product, with only a small percentage of members switching to an alternative biologic. The change to the biosimilar product resulted in an average of an 80-83% discount per prescription. Additionally, 2024 marked the adoption of ‘rebate credit’ contractual language established by PBMs to help shift the market towards the lower net cost biosimilar products.

As biosimilars cultivate more awareness in the marketplace and amongst providers, it is expected the adoption of biosimilar products will continue to grow over the next few years. Already in 2025, we have seen the launch of six Stelara (ustekinumab) biosimilars. With Stelara generating $20 billion in annual sales2, biosimilars represent another key opportunity for plan sponsor savings.

The big three PBMs have taken different approaches to the adoption of Stelara biosimilars. Originally, none of them opted for an exclusionary approach, citing supply chain concerns as the primary reason for placing the Stelara biosimilars at parity with the reference product. However, Optum Rx will be moving to exclude the reference product from its Premium Standard Formulary, effective July 1, 2025.

The big three’s Stelara adoption plans

  • On January 1, 2025, Optum Rx added the biosimilar Wezlana at parity with Stelara. Effective July 1, patients will be transitioned over to the biosimilar as the PBM moves to exclude the reference product. This will be done through its subsidiary Nuvaila, where it will be offering both low-wholesale acquisition cost (WAC) and high-WAC versions of the biosimilar. To promote the adoption of the lowest net cost option, our team negotiated to prefer the low-WAC version of the biosimilar and exclude the high-WAC version for all Optum Rx clients.
  • Express Scripts has announced that it will co-prefer low-WAC interchangeable biosimilar, Pyzchiva, available through its subsidiary Quallent, alongside the biosimilar, Yesintek and the reference product, in 2025.
  • CVS Caremark, the first PBM to announce the exclusion of the Humira biosimilars has announced that it will move forward with adding the following Stelara biosimilars at parity: Yesintek, Pyzchiva (Sandoz®) and Pyzchiva (Cordavis), effective July 1, 2025.

Currently, seven biosimilars have been approved as noted in (Figure 2), with one remaining Stelara biosimilar in the pipeline. Manufacturers of the launched products have reported an average discount off the list price of Stelara of 80-96%. As of Q1 2025, Employers Health has not seen any uptake of the launched products.

In March 2025, the Food and Drug Administration announced the approval of the first interchangeable biosimilar for Xolair, Omlyclo® (omalizumab-igec). This marks the first respiratory biosimilar on the market. Omlyclo® will be available as 75 mg/0.5 mL and 150 mg/1 mL solutions in a single-dose prefilled syringe. The entrance of numerous biosimilar products is an exciting advancement in the pharmaceutical space and represents a significant opportunity for plan sponsors to reduce specialty drug costs.

FIGURE 2

Approved Biosimilars

Product Manufacturer Approval Date Interchangeability Status Granted?
Wezlana* Amgen October 2023 Yes
Selarsdi* Teva April 2024 Yes
Pyzchiva* Sandoz June 2024 Yes
Otulfi* Fresenius September 2024 Yes
Imuldosa Accord October 2024 No
Yesintek* Biocon November 2024 No
Steqeyma* Celltrion December 2024 No

Source: IPD Analytics; *products launched as of April 30, 2025

Specialty drug spend management

Specialty drug spend continues to be a driver of health care costs. In 2024, specialty medications accounted for only 1.6% of total prescriptions but roughly 47% of total gross costs. While the introduction of biosimilars aims to normalize this trend, advancements and innovation in the specialty pharmacy space continue to grow. While the standard PBM arrangement typically offers utilization management around these medications, typically PAs or step therapy, the pace of innovation may outstrip the updates to management.

The Employers Health clinical team has continued to develop strategies aimed at managing high-cost specialty therapies. Custom clinical strategies have been a pivotal approach to improving financial management and patient outcomes. Through implementing Employers Health tailored clinical criteria, clients have significantly improved the overall management of various therapeutic classes. Clients who have chosen to implement our existing clinical strategies have seen savings up to $75.90 PMPM (Figure 3). With prior strategies primarily focusing on non-specialty medications, we are pleased to announce the launch of our 2025 specialty custom clinical strategies. These strategies are designed to be clinically robust while offering the potential for greater cost savings for plan sponsors.

Managing the ever-evolving pharmaceutical landscape has proven to be both challenging and full of opportunities for plan sponsors. Clients who are seeking effective clinical management opportunities in 2025 are encouraged to explore Employers Health custom strategies. Despite these complexities, the Employers Health team, with your help, remains committed to helping our plan sponsors navigate the current pharmacy landscape.

FIGURE 3

Custom Clinical Strategies

Program Top Cost Avoidance PMPM Average Cost Avoidance PMPM Total Cost Avoidance
Employers Health anti-obesity PA $40.52 $17.79 $6,560,920.26
Auvi-Q* $0.63 $0.16 $179,313.59
Dermatological bundle 1.0* $1.22 $0.19 $83,671.68
Descovy* $2.54 $0.94 $369,772.05
Dry eyes $3.56 $0.58 $22,609.04
Duexis/Vimovo $0.41 $0.19 $26,519.04
Gastrointestinal motility $1.02 $0.43 $215,551.08
High-cost generics 3.0 $0.94 $0.24 $362,608.15
High-cost generics 4.0 $0.53 $0.11 $25,475.04
Rosacea management $0.75 $0.10 $529,074.30
Sleep step therapy $23.78 $4.38 $2,085,165.00
Grand total $75.90 $25.11 $10,460,589.23

Custom clinical strategy case studies based on Jan-Jun 2024 data
*Affordable Care Act FAQ Part 68 may limit ability to offer this program

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