As the pharmacy benefit management (PBM) industry continues to evolve, a handful of key PBM trends are reshaping the landscape for employers, healthcare providers, and patients alike. Driven by a push for transparency, the demand for more affordable, effective treatments, and innovative therapeutic options, PBMs are experiencing unprecedented challenges and opportunities.
Four major trends stand out as pivotal in 2025 and beyond: the movement toward transparent PBM models, the expanding role of GLP-1 therapies, the rise of biosimilars to bring cost-effective alternatives to the market, and the thoughtful integration of high-cost gene therapies. Together, these developments highlight both the necessity for reform in the PBM industry and the promising avenues available to deliver more accessible and affordable healthcare options.
Here’s a closer look at each trend and the changes they signal for the future of PBMs.
Trend #1: Emerging PBM Models Driven by Demand for True Transparency
The pharmacy benefit management (PBM) industry is at a crossroads. The demand for transparency in PBM practices has grown as traditional models, often marked by opaque pricing and complex rebate structures, leave clients frustrated.
The Pressure to Change
Employers are losing patience with traditional PBMs (often referred to as “the big 3”) as legal and regulatory scrutiny intensifies. Many employers are openly dissatisfied with their PBMs, citing misaligned incentives and escalating drug costs that don’t reflect client or patient needs.
These pressures have escalated due to high-profile legal actions, such as Wells Fargo’s lawsuit against its PBM. Wells Fargo claimed that its PBM overcharged for prescription drugs, bringing to light issues with traditional PBM models. The dissatisfaction among employers has raised an essential question: Is the traditional PBM model broken?
Adding fuel to the transparency movement, the Federal Trade Commission (FTC) filed an antitrust and consumer protection lawsuit against the three largest PBMs, alleging that they profited from inflated insulin prices by steering patients toward higher-cost medications. This lawsuit has amplified scrutiny, with both employers and regulators calling for a more consumer-centric approach to PBM services.
This dissatisfaction has catalyzed a movement toward transparency, pushing traditional PBMs to reevaluate their approaches or risk losing market share.
Employers and New PBM Models
In response to growing concerns, employers are actively seeking PBMs that operate with transparent, accountable models, shedding hidden fees, spread pricing, and rebate markups.
Emerging PBM models, such as those from Mark Cuban’s Cost Plus Drugs, offer a clear pricing structure where costs are disclosed upfront, and savings pass directly to clients without confusing rebate structures. This innovative approach not only meets the demand for transparency but also builds trust among clients by aligning PBM goals more closely with client interests.
Cost-plus and rebate-free models are leading the charge. These models bypass traditional rebate structures, passing savings directly to clients and making it clear how much employers pay versus what is spent on medications.
Highlighting the growing demand for change, Blue Shield of California made headlines by dropping CVS Caremark as its PBM in favor of a more transparent and innovative strategy. Partnering with companies like Amazon Pharmacy and Mark Cuban’s Cost Plus Drugs, Blue Shield aims to bypass traditional PBM structures, focusing on value-based pricing and direct relationships with pharmaceutical partners.
Adoption of Transparent Tools and Technologies
Transparent PBMs are leveraging technology to empower clients, offering real-time cost-tracking tools that allow employers and employees to see the true costs of medications, enabling smarter financial decisions.
By giving clients direct access to pricing data, transparent PBMs create a level of accountability and trust that traditional models struggle to match. These technology-driven solutions are essential for PBMs to meet changing market demands and adapt to the new era of transparency.
Trend #2: The Rise of GLP-1 Therapies for Diabetes, Weight Loss, and Expanded Indications
GLP-1 therapies have captured considerable attention, especially as they address two of the most prevalent health concerns: diabetes and obesity. These therapies, such as Ozempic and Wegovy, initially gained traction as highly effective options for managing type 2 diabetes. With new brand options that include an expanded indication for weight loss, utilization and costs are through the roof.
Researchers are exploring even more indications, including potential treatments for cardiovascular issues and even Alzheimer’s disease. Meaning what is already a cost challenge for employers and patients alike will likely be ramped up in the coming years.
Cost and Access Challenges
GLP-1 therapies put considerable strain on the healthcare system as a whole. A recent poll indicates that one in eight adults has used a GLP-1, with 38 percent using them specifically for weight loss. This trend is expected to continue. One analysis estimated that almost 50 million adults in employer plans meet the clinical criteria for taking GLP-1s. And it’s estimated that, by 2030, 30 million Americans will use GLP-1s. At their current price tag, that’s a sobering number.
A one-month supply of popular brand-name options can cost as much as $1,400. On an annual basis, the cost could easily exceed $15,000 per patient!
PBMs face a balancing act – ensuring employee access to these life-improving treatments while managing costs. Employers, in response, are looking for innovative ways to provide access without destabilizing their benefit plans.
Strategies for Cost and Utilization Management of GLP-1s
To address these cost challenges, PBMs are adopting formulary management techniques, such as prior authorization, to control GLP-1 access and costs.
Corporate wellness point solutions are another option, offering a unique approach by providing employees access to affordable GLP-1 therapies through customized treatment plans, comprehensive care management, and clinical oversight.
Future Outlook
As research into GLP-1 therapies’ expanded indications continues, demand is expected to grow. PBMs must develop sustainable, transparent strategies to balance access to these therapies with cost control. In response to client expectations, we may see the rise of more innovative, flexible benefit designs that prioritize clear pricing and patient outcomes.
Trend #3: Biosimilars Continue to Disrupt Markets, with Stelara as the Next Major Milestone
Biosimilars have become a major area of focus in the PBM industry, offering affordable alternatives to high-cost biologics. Biologics serve as essential treatments for conditions ranging from autoimmune disorders to cancer. And, over the past five years, the U.S. biologics market has grown by an average of 12.5 percent annually, with biologics now accounting for 46 percent of total spending.
So, there is ample opportunity for biosimilars to help employers and patients save money on these critical therapies.
The recent launch of biosimilars for Humira demonstrated the potential for biosimilars to significantly reduce costs for employers. However, adoption fell short of early expectations due, in large part, to the traditional PBM model and the influence of the three largest PBMs. It wasn’t until CVS Caremark removed Humira from its formulary in April of 2024 that adoption of biosimilars started to gain traction.
So, what’s next for biosimilars?
Stelara: The Next Big Test
Next up to potentially transform the biosimilar market is the emergence of Stelara biosimilars, which will help manage costs for autoimmune diseases like Crohn’s disease and psoriasis. To date, the FDA has approved five biosimilars for Stelara, with more in the pipeline. But given the slow uptake of Humira biosimilars, what can we expect from these five Stelara alternatives?
The market may see a faster adoption rate for Stelara biosimilars as payers become more comfortable with the concept of biosimilars and their potential cost savings and PBMs opt for a more forward-looking approach such as those adopted by market disrupters.
Market Disruptors Paving the Way for Increased Biosimilar Adoption
While traditional PBMs were originally slow to help drive widespread biosimilar adoption, market disruptors like Mark Cuban’s Cost Plus Drugs have stepped in to accelerate access to these lower-cost alternatives.
By removing the typical rebate and markup structures, Cost Plus provides transparent, low-cost options directly to consumers. This approach not only increases adoption rates of biosimilars but also challenges traditional PBMs to rethink their formulary management and pricing strategies.
Blue Shield of California is also making bold cost-cutting initiatives. In a significant move, the insurer slashed the price of the Humira biosimilar adalimumab-aacf by 75 percent. By bypassing traditional PBM structures and prioritizing transparent pricing, Blue Shield highlights a growing trend of insurers taking matters into their own hands.
As more disruptors enter the market – and more healthcare stakeholders make bold moves – we can expect an increased push for accessible, cost-effective biosimilars, which could shift the balance of power and pricing transparency within the PBM industry.
Trend #4: Gene Therapies and the High-Cost, High-Value Equation
Gene therapies are groundbreaking for healthcare, offering potential cures for genetic disorders like hemophilia, spinal muscular atrophy, and certain forms of cancer. They sometimes fall under the category of “orphan drugs,” which target rare conditions affecting fewer than 200,000 people in the U.S.
Gene therapies present both a remarkable opportunity and a profound financial challenge – especially for self-insured employers, who assume financial risk directly. We’re talking about life-changing (and often life-saving) therapies. But they come with astronomical costs, often reaching millions of dollars per patient.
Take Zolgensma, for example. Zolgensma is a gene therapy for spinal muscular atrophy (SMA) that costs more than $2 million per patient. A staggering figure. But when you consider the alternative – that many babies born with SMA type I often require ongoing, lifelong care – the cost of one treatment (not to mention the elimination of unnecessary pain and suffering) often pales by comparison.
Coverage decisions become even more complex as the gene therapy market continues to grow. There are more than 1,000 gene therapies in development, with the vast majority targeting oncology as well as conditions like sickle cell anemia and Duchenne muscular dystrophy. It’s estimated that, by 2027, spending on cell, gene, and RNA-based therapies could be $12 billion.
The rapidly expanding landscape introduces a complex dilemma for PBMs and employers as they strive to balance access with affordability.
Patient Access and Coverage Decisions
High-cost gene therapies pose complex coverage decisions, requiring PBMs to weigh patient eligibility, treatment effectiveness, and financial sustainability. Given the potential of gene therapies, many employers should consider exploring these options despite their high cost, particularly when effective gene therapy could save substantial healthcare costs over a patient’s lifetime.
PBM Strategies and Innovative Pricing Models
Many PBMs are turning to innovative pricing models to manage financial risk while preserving patient access. Examples include:
- Annuity payment models, which spread the cost of gene therapy over several years, help reduce the initial financial impact and make these treatments more accessible.
- Outcome-based contracts, where payments are tied to the therapy’s success, are becoming popular, ensuring that PBMs and employers only pay for effective treatments.
- Stop-loss programs, where employers can set coverage thresholds, ensuring that catastrophic claims, such as the cost of a single gene therapy, are capped.
PBM Trends: Looking Ahead and Embracing Innovation and Accountability
The pharmacy benefit management industry is at a turning point, with traditional models increasingly seen as inadequate. In response to employer demands for transparency and cost-effectiveness, PBMs must embrace new models and adapt to evolving market trends. Each of these PBM trends – transparent PBM models, the rise of GLP-1 therapies, expanding biosimilar markets, and the promise and challenges of gene therapies – reflects the shifting landscape and the pressing need for innovation in PBM.
As PBMs adapt to a shifting landscape, embracing technology, transparency, and innovative pricing will be essential. The future of PBMs lies in their ability to prioritize client needs, foster affordability, and create lasting value for employers and patients alike. Those PBMs that respond to these demands with proactive, flexible solutions will be best positioned to lead the way in a rapidly changing healthcare environment.
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