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Commission hears PBM reform, GLP‑1 utilization and high IDR awards driving costs
Summary
Staff warned Pharmacy Benefits Management reforms, higher GLP‑1 drug use, and litigation over PBMs are influencing employer costs; the report highlighted Q4 2024 IDR median determinations at 459% of the QPA, noting increased IDR volume that favors providers.
Commission staff briefed members on prescription-drug pressures facing employer plans. The report noted national PBM reform activity in 2025 and litigation alleging collusion between drug manufacturers and PBMs that is contributing to higher insulin and generic drug costs.
On out-of-network disputes under the No Surprises Act, staff said Q4 2024 median IDR determinations where providers prevailed were 459% of the Qualifying Payment Amount (QPA), and that the number of IDR cases exceeded projections, producing provider-favorable outcomes and complicating cost-control efforts. "In Q4 2024...the median payment determination was 459% of the Qualifying Payment Amount (QPA)," the report stated.
