During Asembia 2025, Rebekah Gregg, chief operating officer at Pharmaceutical Strategies Group (PSG), led a comprehensive session focused on specialty benefit design. The discussion centered around the findings from PSG’s newly released "Trends in Specialty Benefit Design Report." This report is based on a national survey of over 230 health care benefits leaders, including those from managed care organizations, employers, and unions.

Key Objectives and Findings

Gregg emphasized that the primary objectives for managing specialty medications in 2025 are controlling the overall specialty trend and reducing total cost of care. Survey data indicated a growing focus on cost management, with 84% of respondents identifying these as top priorities—up from 75% the previous year. Additionally, reducing inappropriate utilization remains significant, as nearly half of respondents ranked it as the second or third priority.

Challenges in Specialty Drug Management

Morgan Lee, senior director of research and strategy at PSG, highlighted that accessing actionable, integrated pharmacy and medical data remains the top challenge, with growing difficulty reported year over year. In particular, biosimilar strategy implementation has become increasingly challenging, reflecting the complexities introduced by Humira biosimilar strategies in 2024.

Renee Rayburg, vice president of clinical strategy at PSG, noted that while Humira biosimilars have been on the market since 2023, brand Humira maintained a significant market share through 2024, partly due to the slow adoption of biosimilars and concerns around rebate structures.

Evolving Rebate Strategies

The session addressed ongoing questions around rebate-driven strategies, particularly in light of shifts seen with insulin price decreases and biosimilar launches. While respondents expressed some interest in alternatives—such as lower-cost drugs without rebates—actual implementation of these strategies remains limited.

Navigating Cell and Gene Therapies (CGT)

Cell and gene therapies remain an area of significant concern among payers, with most respondents anticipating affordability challenges over the next 2 to 3 years. Despite advancements, knowledge gaps persist, highlighting a need for more data and education to adequately assess financial risk.

Rayburg pointed out that while uptake of gene therapies for conditions like hemophilia and sickle cell disease has been slower than anticipated, coordination complexities and real-world challenges impact the practical adoption of these high-cost treatments.

Oncology Benefit Design

The session also addressed oncology management, where respondents reported limited adoption of newer cancer screening technologies and biomarker testing. While one-third of health plans cover blood-based cancer screening tests, the proportion is lower among employers. Additionally, while 30% of respondents are utilizing oncology management vendors, the potential for employing site-of-care strategies in oncology remains largely untapped.

Looking Ahead

As specialty drug costs continue to rise, the focus on optimizing drug management strategies is sharper than ever. PSG's ongoing research aims to provide health care payers with the insights needed to navigate complex drug landscapes and make data-driven decisions to enhance affordability and patient outcomes.