By Mark Campbell
Prescription drug costs continue to spiral upward, leaving employers scrambling to offer robust pharmacy benefits while keeping costs sustainable. Every year, tens of billions of dollars flow into high-cost therapies. Treatments like GLP-1s, originally approved for diabetes and obesity-related weight loss, are seeing a surge in utilization – often for lifestyle-related reasons – and new specialty drugs with hefty price tags continue to be developed and launched.
While effective, given their cost, these treatments have the potential to cripple employer healthcare budgets. Without effective strategies to ensure the right patients get the right drugs at the right time, employers risk pouring money into inefficiencies, over-prescribing, and even misuse while missing critical opportunities to improve health outcomes.
That’s why strategic clinical management targeted at the highest impact categories is essential for managing costs while ensuring appropriate access. By ensuring medication regimens align with U.S. Food and Drug Administration approval criteria and implementing strategies to prevent misuse, effective clinical management doesn’t just trim excess pharmacy spend fat – it ensures every healthcare dollar delivers measurable cost savings while improving outcomes.
Here are four key trends causing pharmacy plan bottom lines to balloon and why effective clinical management strategies are an absolute necessity to combat the costs and complexities of today’s pharmacy benefits.
1. Ballooning GLP-1 utilization
GLP-1s offer great promise but also pose one of the biggest management pharmacy benefits challenges. Driven by celebrity endorsements and viral social media campaigns, GLP-1s are experiencing a frenzy of utilization.
In 2024, GLP-1 use was up fourfold over 2019. Nearly 2 million prescriptions for these drugs were filled in December 2024 alone, four times the number from December 2023.
These high-cost medications are increasingly being used as first-line treatments for their approved indications and often cannibalize other clinically effective branded and generic therapies. They also have a high potential for inappropriate prescribing that is off-label or circumvents plan design, which can add significant costs for self-funded employers. According to RxBenefits analysis, without proper clinical management strategies, up to 40% of GLP-1 prescriptions are outside a plan’s approved use. RxBenefits implemented a GLP-1 review that delivered $52 million in savings in 2024 by ensuring appropriate use.
2. Direct-to-consumer advertising
Direct-to-consumer (DTC) advertising has become a multi-billion-dollar industry designed to influence patient behavior and prescribing patterns. In 2024, pharmaceutical companies were television’s largest advertisers, spending $4.5 billion on TV ads alone.
The result? A cascading effect that creates multiple challenges, including driving demand for expensive treatments, potential off-label prescribing, and spiraling costs.
For instance, specialty dermatology treatments were a major innovation when they were first introduced, offering options to patients who previously lacked effective therapies. However, heavy DTC advertising has perpetuated the use of high-cost brand drugs even now that effective lower-cost biosimilar alternatives are widely available.
Research shows that 30% of Americans discuss advertised medications with their doctors, and 53% receive prescriptions for requested drugs. This not only strains doctor-patient relationships, it leads to medically unnecessary prescribing of high-cost branded drugs. Additionally, research found that higher DTC spending is frequently linked to lower clinical benefits, with a 1.5% increase in advertising dollars driving a 10% rise in sales regardless of the drug’s efficacy.
Plan and formulary design that prioritize generics and biosimilars, coupled with appropriate clinical oversight, can keep pharmacy costs in check without negatively affecting member experience or reducing appropriate access.
3. Prescription drift and overprescribing
Many of the top-selling medications in the last 10 years have obtained expanded indications after launch. Since the dosage levels and frequency can often vary between indications, such label expansion can lead to inappropriate prescribing and waste.
For instance, anti-inflammatory drugs like Humira or Stelara, which are approved for a range of indications, often have different dosages depending on the condition. Without human-led clinical reviews, such drugs may get prescribed at higher than necessary doses, adding thousands in annual costs for employers.
RxBenefits offers high-touch interventions for patients with complex specialty conditions called Complex Condition Interventions that help establish review processes that prevent excessive dosing or frequency.
4. Manufacturer tactics to capture and hold on to market share
While prescription drug patents were designed to incentivize the development of innovative treatments by giving manufacturers a period of exclusivity, they have become a tool for them to extend that nearly indefinitely. By deploying tactics like extending patent exclusivity by making minor changes to the formulation or method of administration, and pay-for-delay, brand drug makers successfully held on to lucrative market share and kept competition from cheaper alternatives at bay. For instance, Humira, which was first approved in 2002, didn’t see the launch of the first biosimilar until 2023 thanks to AbbVie’s successful “patent thicket” around the drug.
Manufacturers further promote utilization of expensive brand drugs over cheaper alternatives through copay coupons, which shield patients from the true cost but ultimately lead to much higher costs for employers.
Clinical management is a strategic imperative
As such challenges intensify, employers who either don’t implement or delay clinical management solutions could find themselves trapped in an escalating cost spiral with diminishing control.
RxBenefits offers comprehensive, targeted clinical management with a unique human-led model. While automated systems rely on inflexible protocols, RxBenefits combines strategies such as formulary optimization and clinician-led decision making – reducing waste while maximizing therapeutic outcomes.
The result is a dual advantage that offers significant benefits: immediate cost control and long-term sustainability with a focus on enhanced outcomes.