2024 in review

The rise of the GLP-1 class of obesity drugs is not exactly breaking news anymore. What is new is the gathering realization that these medications are not a passing fad.

First, the class has already expanded beyond just GLP-1s. It now includes similar-acting drugs that also target the gastric system, called GIP (glucose-dependent insulinotropic polypeptide). There are currently 45 GLP-1/GIP drugs intended for obesity in the development pipeline.

Second, GLP-1/GIP drugs for obesity seem poised to expand into other therapeutic areas. Recent clinical trials have examined the use of GLP-1s to treat heart disease, sleep apnea and kidney disease.

In the meantime, plan sponsors are learning that these drugs can’t work all by themselves. Rather, they require a carefully constructed support system that can help members actually modify their health habits in order to get significant weight loss that persists for a lifetime.

Sign up for the Optum Rx webinar on "Rethinking Weight Management and Wellness."

The shift toward biologic drugs is one of the biggest contributors to higher health costs. While only 1-2% of the U.S. population uses biologic products, they account for nearly half of all national prescription drug spending.

Biosimilars are intended to encourage competition for expensive biologic drugs. But getting to that point isn’t easy. One very good illustration of some of the opportunities and pitfalls on the way to significant cost savings is what happened with the biosimilars for the mega-blockbuster, Humira®.

Many more biosimilars are coming soon.

Thanks to our experience with Humira, Optum Rx has already developed a robust and sound set of guiding principles that will direct our efforts to bring clinical quality and cost savings to our customers.

Attempts to reign-in the rising cost of drugs have taken many forms over recent years. In 2023, there’s been a crescendo of activity aimed at controlling the purported influence of pharmacy benefit managers (PBMs) on higher drugs costs. Both the House and Senate have been considering changes to how prescription drug benefits are managed, with more than 600 bills impacting PBM clients introduced just this year.

But the biggest change has already happened. On Aug. 15, the Centers for Medicare and Medicaid Services (CMS) announced new, lower prices will go into effect January 1, 2026, for the 10 Medicare Part D drugs selected under the Inflation Reduction Act. The selected drugs accounted for about 20% of total Part D gross spending in 2023. The CMS-negotiated prices range from 38% to 79% discounts off list prices.

The real question, though, is what happens now with a new presidential administration. We could try to guess, based on public statements from various figures who may serve in policy roles next year. But the truth is, we don’t know.

Optum Rx will continue to monitor these developments and report back to you.

In the early 2000’s the prevailing business model in drug manufacturing focused on big-selling brand name drugs that treated millions of patients. Good examples include Lipitor® for high cholesterol and Prilosec® for gastric reflux.

Toward the middle of the 2010’s, pharmaceutical makers faced a “patent cliff” that resulted in many high-priced brand name drugs being replaced by generics. Stung by the loss in revenue, pharma started to focus on smaller populations using more complex (biologic) drugs that could command very high prices. Here, think of Keytruda® for cancer, or Humira for inflammatory disease.

And as we progress through the current decade, this trend is accelerating. In this cycle, we are seeing high-cost biologic drugs being used with many patients in each of the top three drug classes by spend: immunology, oncology, and diabetes. As we’ve discussed, GLP-1s for weight loss are charging hard to enter that top spending tier for the same reasons.

What can you do? Begin with innovative formulary structures and clinical programs from Optum Rx. Your Optum representative can help plan sponsors design a plan to meet the challenge of expensive biologic and GLP-1 drugs.

As widespread use of the internet enters its third decade, healthcare has been lagging in the digital revolution for various reasons. But, the COVID-19 pandemic seemed to open some new doors for things like telehealth, while platforms like email, text messages, and mobile apps have simplified how people communicate with physicians and pharmacists.

That said, long after digital communications have become the norm elsewhere, printed materials are still used to convey important information to pharmacy plan members.

Plan sponsors are ideally positioned to influence their members to go paperless and embrace digital self-service. Aside from being more personalized and convenient, plan sponsors find that digitizing pharmacy communications can both improve member satisfaction and lower the cost of care.

While the operational side of the pharmacy care services business rarely garners headlines, our operations teams are vital to making prescription medications accessible and affordable.

Want to learn more? Join senior Optum Rx leaders as they discuss how ongoing innovations in operations are helping to improve the pharmacy benefit management experience for plan sponsors, providers, and members.