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Market Insights & Industry Trends

Regulatory

  • Prior Authorization remains a top concern, with regulations pending in over 20 states. Step therapy and specialty matching are emerging as key drivers of regulatory changes in 17 states. Additionally, the adoption of Artificial Intelligence is on the rise, with implementation underway in 5 states.
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Data Insights

  • Overall Surgery Overturn Rate average = 27%
  • Highest Appeal Overturn Rate (Surgery Subcategory)
    Eye and Ocular Adnexa 40%
    Mediastinum and Diaphragm 33%
    Cardiovascular System 33%
    Respiratory System 32%
    Hemic and Lymphatic Systems 31%
  • Lowest Appeal Overturn Rate (Surgery Subcategory)
    Musculoskeletal System 26%
    Auditory System 25%
    Integumentary System 23%
    Female Genital System 22%
    Digestive System 22%
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Pharmacy

  • Innovative strategies in managing high-cost specialty medications (including GLP-1s can significantly impact plan drug spend)
  • Ozempic shows clinical benefit in patients with heart failure
  • The PBM marketplace is more competitive than ever. High levels of satisfaction can increase customer retention and lifetime value,1 so customer satisfaction is a key differentiator. Drug benefit management is increasingly complex, and plan sponsors depend on PBMs to deliver services seamlessly and help control costs.2
    A few key data points to ponder2

    • Overall satisfaction is at its lowest point since 2014
    • NPS decreased to 8 in 2023 and varies by respondent group
    • PBMs have room to improve in helping plans address the affordability of high-cost gene therapies
    • Respondents see both strengths and weaknesses of disruptive solutions like Amazon Pharmacy and Cost Plus Drugs

1 Otto AS, Szymanski DM, Varadarjan R. Customer satisfaction and firm performance: insights from over a quarter-century of empirical research. J. Acad. Mark. Sci. 2020;48:543-564.
2 Pharmacy Benefit Manager Customer Satisfaction Report

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Health

  • The U.S. Food and Drug Administration approved two milestone treatments, Casgevy and Lyfgenia, representing the first cell-based gene therapies for the treatment of sickle cell disease (SCD) in patients 12 years and older1
  • FDA approves cure for sickle cell disease, the first treatment to use gene-editing tool CRISPR2

1 FDA Approves First Gene Therapies to Treat Sickle Cell Disease
2 Groundbreaking approval for gene-editing tool CRISPR

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