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Specialty drugs drive pharmacy spend; rebates and biosimilars cut net costs
Summary
UMR told the board specialty medications accounted for about 49% of pharmacy spend while representing roughly 2.3% of members; rebates reduced gross pharmacy PMPM from $224.54 to a net of about $150.14 for the plan year.
UMR's pharmacy presentation showed the district paid about $224.54 per member per month in pharmacy costs for the May 2024'Apr 2025 plan year, with total plan-paid pharmacy spending in the roughly $10.4 million range. Specialty drugs represented nearly half of that spend while being used by a small number of members.
Presenters said manufacturers'rebates offset roughly 32% of pharmacy plan-paid costs (about $3.1 million), which lowered the net plan-paid PMPM to about $150.14. They also explained the board's top-20 drug list (by plan-paid dollars), noting Stelara and Humira among the costliest single-drug items and that biosimilar substitutions (required July 1) will reduce future costs. "On average, it's about $500 to $600 less per fill," a presenter said of biosimilars.
Board members asked for details about utilization, formulary design and how GLP-1 injectables would be categorized; presenters said GLP-1s (e.g., Ozempic) were treated as traditional drugs in this reporting and emphasized formulary and rebate negotiation as levers to lower net cost.
