New Survey Reveals 84% of Payers Prioritize Total Cost Management as Cell and Gene Therapies Present Unprecedented Challenges
Employers and health plans are actively responding to the challenge of rising specialty drug costs, according to the newly-released 2025 Trends in Specialty Drug Benefits Report from Pharmaceutical Strategies Group (“PSG”), an EPIC company. The report was co-sponsored by Genentech and has been published for 12 years. Based on in-depth survey responses from more than 230 pharmacy benefit leaders, the report provides a comprehensive look at how organizations are managing complex, high-cost therapies and exploring innovative specialty drug management strategies.
“Leaders are eager to try new approaches to address costs while preserving access to drugs that their members need. Yet many benefit leaders lack the data, infrastructure, and confidence to fully implement those strategies,” said Rebekah Gregg, Chief Operating Officer of PSG. “Transparency and clear, data-driven insights will be vital to adapt to the pressures payers face.”
Key findings from the report include:
Cost Management Dominates the Agenda. 84% of respondents said managing specialty drug costs or total cost of care is their top priority—up from 75% last year.
Rebates and Traditional PBM Pricing Models Under Pressure. Many payers want alternatives to traditional arrangements. 80% are interested in favoring lower-cost drugs that offer no rebate at all, and over 60% are interested in cost-plus pricing models.
“Payers want change, but so far relatively few have made the leap due to the complexity of shifting to new types of arrangements,” said Morgan Lee, PhD, MPH, CPH, Senior Director of Research and Strategy at PSG. “Our data speak to the appetite for more transparent models that may also help control specialty drug costs for payers and patients.”
Impact of Cell and Gene Therapies (CGTs) Remains Unclear. While 73% of plans expect CGTs to pose a moderate or major financial challenge in the next 2–3 years, most express low confidence in their understanding of the financial impact. What’s more, nearly 40% don’t currently use any financial protection product to manage their financial risk related to CGTs.
“These therapies aren’t one-size-fits-all,” said Renee Rayburg, RPh, Vice President of Clinical Strategy at PSG. “Not only do gene therapies present financial challenges, they’re also complex in terms of which patients are eligible as well as the treatment process, and demand is higher for some gene therapies than others. Payers need expert analysis that considers their population, pipeline exposure, and vendor ecosystem.”
Data Gaps Undermine Cost Management. Plans are especially challenged by cost-sharing affordability for members and the lack of reliable data to understand the total cost of care impact of medications. Access to actionable integrated pharmacy and medical data is also a challenge for many as they implement and evaluate specialty drug management strategies.
Utilization Management Carveouts Gain Traction. 9% of employers and 24% of health plans currently carve out one or more utilization management services. An additional 24% of plans are considering the adoption of these carveouts, which would delegate components like prior authorization, step therapy, or other specialty drug management strategies to vendors that may offer greater transparency, cost control, or alignment with the plan’s goals than traditional PBMs.
"Specialty drugs have ushered in remarkable advancements in patient outcomes and quality of life, yet they also introduce significant affordability challenges," said Ted Henderson, VP National Accounts at Genentech. "Our hope is that the insights in this report will foster conversation across stakeholders in the healthcare industry about how to address these challenges and opportunities."
Download the Trends in Specialty Drug Benefits Report and register for the webinar here.
About the Trends in Specialty Drug Benefits Report
PSG has been researching and reporting on drug benefit design for over 25 years. This year’s Trends in Specialty Drug Benefits Report is in its twelfth year of publication and takes an in-depth look at trends and best practices in specialty drug benefits. It is based on results from an annual survey of individuals representing employers, health plans, and unions/Taft-Hartley plans. PSG fielded this comprehensive survey in September and October of 2024.
About Pharmaceutical Strategies Group (PSG)
Pharmaceutical Strategies Group, an EPIC company, relentlessly advocates for clients as they navigate complex and ever-changing drug cost management challenges. PSG functions as a strategic partner through industry-leading intelligence and technologies to realize billions of dollars in drug cost savings for clients every year. www.psgconsults.com
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Contacts
Gregory FCA for EPIC
epic@gregoryfca.com