How a Transformational Shift in Pharmacy Benefits Will Impact Payers in 2025
Payers are leveraging innovative pharmacy benefit strategies to shift toward more patient-centered and accessible healthcare.
The upcoming year marks a nationwide movement towards more patient-centric, efficient and accessible healthcare, pushing payers to embrace innovative pharmacy benefit strategies that enhance personalized care and drive better outcomes while reducing costs. With a projected double-digit rise in prescription drug trends for 2025, industry shifts present valuable opportunities to manage increasing medication expenses.
AscellaHealth’s expert teams are helping payers explore reimbursement adjustments and benefit management approaches that ensure better access to high-quality treatments.
Key 2025 Trends to Watch and AscellaHealth Solutions to Combat Rising Prescription Drug Costs
1. Increased Spending on Prescription Medications and Specialty Drugs
In 2024, the cost of drug benefits per employee increased by 7.2%, with prescription medications remaining the fastest-growing segment of health benefit expenses. The upward trajectory has been driven in part by the rising availability and utilization of high-cost cell and gene therapies (CGTs).
The increasing costs of both home-administered and facility-based prescription drugs are consuming a larger portion of healthcare spending. In fact, 76% of employers report being “very concerned” about the rising pharmacy costs. In stark contrast, just 1% believe the current prescription drug market is competitive enough to drive down prices and improve affordability.
Over six million Americans are currently taking a specialty drug, and this number is expected to exceed eight million by 2025. As a result, the U.S. specialty drug market projects to surpass $1 billion in annual spending within the next five years.
AscellaHealth’s Response:
While the cost-reducing impact of biosimilars has been slower than expected, AscellaHealth collaborates with payers to develop strategies that maximize savings. This includes shifting utilization toward biosimilars, which has led to several AscellaHealth clients adjusting their formulary strategies for 2025 by removing certain brand-name drugs in order to reduce overall costs.
2. Expanding Employer Participation in Captive Insurance
The increasing cost of healthcare, along with the high expense of specialty drugs and infusion therapies, are driving more employers to explore captive insurance solutions that include medical stop loss captives. These captives allow small to mid-sized employers to pool their resources, creating economies of scale that lead to significant savings and improved healthcare outcomes. Captives also provide employers greater flexibility in managing pharmacy benefits, enabling more informed decisions regarding brand-name drugs, generics and coverage options.
AscellaHealth’s Advantage:
Optimizing site of care for infusion therapy presents a significant opportunity for substantial savings. Payers can boost patient engagement and compliance by offering members access to more convenient, quality-focused settings, resulting in better clinical outcomes and lower costs.
AscellaHealth has leveraged its extensive industry knowledge and expertise to develop a proprietary Home Infusion Pharmacy Network. It offers payers and patients a less intrusive, more cost-effective alternative to hospital-based infusion therapy.
3. The Growing Burden of Prescription Drug Costs
Prescription drugs impact nearly every American. Affordability continues to be a major concern and surveys reveal that approximately six in ten adults take at least one prescription medication, with approximately 37% taking three or more medications. Many insured adults report delayed or skipping necessary care or medications due to cost, with about one in five adults unable to fill a prescription because of its price.
AscellaHealth’s Financial Solutions and Co-pay Assistance:
AscellaHealth’s specially trained Patient Care Coordinators (PCCs) assist members in navigating financial support solutions. These programs aim to make medications more affordable, enhance access to treatments and improve medication adherence.
For low-income, underinsured health plan members, PCCs can connect them with patient assistance programs that provide free or low-cost medications. Additionally, they help guide insured members to co-pay assistance programs, reducing out-of-pocket expenses and helping individuals and families manage financial challenges while accelerating access to necessary treatments.
4. Escalating Cancer Treatment Costs
The rising costs of cancer treatment are a significant concern, with Aon analysts predicting an annual increase of 11-21%. In response, employers are reassessing their benefits to more effectively manage these escalating expenses. According to a survey by The Business Group on Health, 80% of employers recognize cancer as a primary cost driver. By 2025, 49% plan to incorporate cancer-focused Centers of Excellence (COEs) to provide coordinated, high-value care for complex conditions.
AscellaHealth’s Targeted Oncology Solutions:
AscellaHealth recognizes the substantial financial burden of cancer treatment and collaborates with payers to provide targeted oncology management solutions. By forming value-driven partnerships with COEs and patient support programs, AscellaHealth helps payers optimize oncology costs while maintaining high-quality care. Our PCCs offer personalized assistance, guiding members through access to crucial financial support programs and helping them stay on track with their treatment plans—ultimately enhancing clinical outcomes and generating cost savings for payers.
5. Increasing Prevalence of High-Cost Claims
High-cost claims are expected to be an increasing challenge for employers in 2025, primarily driven by the use of novel, expensive CGTs. These therapies, which have the potential to halt or even reverse symptoms with a single treatment or short series, present a significant financial burden for payers. With at least 30 new CGTs anticipated to gain FDA approval by 2025—each costing between $1 million and $5 million per treatment—a strategic approach is crucial. The financial impact of gene therapies is rising steadily, with monthly spending on these treatments projected to surpass $2 billion by 2026.
AscellaHealth’s Approach:
To strike a balance between access and affordability for CGTs, AscellaHealth helps payers shift to value-based purchasing contracts (VBCs) that tie payment to the effectiveness and real-world outcomes of treatments over time.
Navigating the Future of Pharmacy Benefits
As 2025 approaches, these transformative trends present both challenges and opportunities for payers seeking to balance cost management with enhanced patient care. AscellaHealth is committed to helping payers through comprehensive solutions that improve efficiency, expand access and deliver better outcomes for members.
Contact AscellaHealth at info@ascellahealth.com or click here to discover our expertise and tailored strategies that can assist you in navigating the evolving landscape of pharmacy benefits.