What's driving medical benefit spend? Prime Therapeutics trend report shares new clues

Prime's latest Medical Pharmacy Trend Report offers unified medical and pharmacy claims data for the first time to enable smarter decision-making

EAGAN, Minn., Sept. 4, 2025 /PRNewswire/ -- In today's evolving health care environment, payers are under pressure to manage the rising costs of specialty drugs as the prevalence of chronic diseases increases and an aging population has higher demand for specialty drugs. These drugs, often covered under the medical benefit and administered in clinical settings, make up approximately 55% of specialty spend and come with complex billing, utilization and clinical considerations. To help navigate this challenge, Prime Therapeutics LLC (Prime) released the Medical Pharmacy Trend Report: a data-rich, annually published guide that reveals what's driving spend, where utilization is shifting and how payer strategies are evolving.

Now in its 15th edition, the 2025 Medical Pharmacy Trend Report shows medical pharmacy trends for commercial, Medicare and Medicaid lines of business. This in-depth analysis identifies opportunities for site-of-care optimization and evaluating the impact of biosimilars, gene therapies and new approvals. And for the first time, it includes integrated medical and pharmacy claims data for certain therapeutic categories for commercial and Medicare lines of business, offering a holistic view of total cost of care.

"This year's data underscores the growing complexity of managing medical benefit drugs, especially as innovation accelerates and costs climb," said Kristen M. Reimers, RPh, senior vice president, specialty clinical solutions for Prime. "Our integrated analytics and payer insights help stakeholders navigate these shifts and make informed decisions that balance access, affordability and outcomes."

Key insights from the report include:

• Oncology remains the top spend category, accounting for 40.7% of commercial, 55.5% of Medicare and 39.4% of Medicaid medical drug spend.
• Gene therapies reached record-breaking prices, with atidarsagene autotemcel (Lenmeldy) and eladocagene exuparvovec-tneq (Kebilidi) approved at $4.25 million and $3.95 million respectively.
• Utilization of high-cost therapies ($50,000+ per utilizer) increased significantly, especially in Medicaid (up 38.7%).
• Vaccines and ophthalmic injections surged, with pneumococcal 20-valent conjugate (Prevnar 20) vaccine and faricimab-svoa (Vabysmo) driving notable increases in spend and utilization.
• Pembrolizumab (Keytruda) led drug-level spend across all lines of business, with expanded indications fueling growth.

The report also includes results from Prime's annual payer survey, revealing that:

• 68% of plans utilize value-based contracts or outcomes-based agreements.
• 72% of plans cite managing financial risk as the top challenge in gene therapy coverage.

The full report is available at PrimeTherapeutics.com/Read and includes detailed breakdowns by therapeutic category, drug-level trends, payer strategies and forecasts through 2027.

For a deeper dive into this year's report, register for the Medical Pharmacy Trend Report webcast on Monday, Oct. 13 at PrimeTherapeutics.com/MP-Trends.

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About Prime Therapeutics
Prime Therapeutics LLC (Prime) is a pharmacy solutions partner that delivers savings, simplicity and support to customers and members. Prime provides care to millions of people across the country through pharmacy benefit management, specialty and medical drug management, and state government solutions. Prime creates a new standard for the industry by doing what's right through a conflict-free approach, offering a holistic specialty experience, accessing the most modern technology, and emphasizing purpose beyond profits. To learn more, visit PrimeTherapeutics.com or follow Prime on LinkedIn.

Contact:
Jenine Anderson
Sr. Manager, Public Relations
612.777.5629
[email protected]

SOURCE Prime Therapeutics LLC