The AMCP 2025 panel discussion titled “Employer Perspectives on High-Impact Drugs” opened with moderator Chris Skisak, PhD, executive director, Houston Business Coalition on Health, introducing the topic by highlighting the burden that drug costs place on employer-sponsored health plans. He cited a recent national survey showing that 99% of employers consider prescription drug prices the leading threat to affordability. Dr Skisak emphasized that rising drug claims—especially from high-impact drugs like GLP-1s—are driving plan sponsors to rethink pharmacy benefit management (PBM) strategies.

Nathan Mathews, vice president and senior pharmacy benefits consultant at Milliman, highlighted the tension between employers' desire to provide access to promising medications and the struggle to balance immediate cost pressures against potential long-term savings. Josh Golden, senior vice president of strategy at Capital Rx, underscored that GLP-1s have moved from minor cost factors to primary drivers of health plan expenses, likening the situation to Humira’s (adalimumab) historical dominance but forecasting even higher cumulative costs.

Karen Rakers, MD, vice president of onsite employee clinics and next level PRIME at Next Level Medical, discussed how employers are tightening eligibility criteria for access to GLP-1s due to financial strain. Employers are exploring sourcing medications from abroad or promoting weight loss programs as alternative pathways. Mathews added that employers are increasingly scrutinizing micro-level PBM decisions—such as refill-to-soon policies and early renewals—that, when mismanaged, result in significant cumulative waste and cost inflation.

The discussion shifted to specialty drugs, where speakers highlighted significant advancements in patient care. However, they cautioned that opaque pricing and stop-loss insurance challenges have turned specialty pharmaceuticals into a growing and unsustainable financial risk for employers. Christine Hale, MA, MBA, senior vice president and chief medical officer at Lockton Companies, pointed out that stop-loss insurers are increasingly reluctant to cover the high ongoing costs of chronic specialty drug therapies, leading employers to face 20–30% premium hikes or complete coverage exclusions.

Golden noted that even well-intentioned strategies like promoting biosimilars are hampered by PBMs' financial conflicts of interest, creating barriers to biosimilar uptake. The group criticized the lack of transparency in PBM operations, noting that rebate-driven models often inflate gross costs, leading employers to rethink their procurement processes and demand clearer, more holistic evaluation metrics beyond rebate figures.

A central theme throughout the discussion was the urgent need for reform. Panelists advocated for regulatory changes, greater data access for employers, and structural shifts such as unified claims processing to eliminate silos between medical and pharmacy benefits. They observed that employers must take proactive control, demanding granular data transparency to comply with new legislative requirements, including those under the Consolidated Appropriations Act.

Closing the session, the panel discussed the potential for biosimilar-first mandates, strategies for cost-containment without denying essential care, and the moral hazard created when financial incentives influence prescribing patterns. The speakers stressed that employers must embrace data-driven oversight, reconsider traditional PBM relationships, and align financial incentives throughout the supply chain to sustain benefit affordability and access to innovative treatments.

Reference

Education Session: [M2] Employer perspectives on high-impact drugs. Presented at: AMCP 2025; March 31-April 3; Houston, TX.