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Our medical pharmacy experts are dedicated to keeping you informed so you can make better health care decisions. Visit our website for webinars, podcasts, past trend reports and more:
Lisa Polakowski, PharmD, MBA Medical Pharmacy Trend Report Director
Laura Walters, RPh Director, Specialty Clinical Solutions
Kristen Reimers, RPh Sr. Vice President, Specialty Clinical Solutions
Ben Messerli, ASA, MAAA Manager, Actuarial Services
Vice President, Pharmacy Management Medical Mutual of Ohio
Scott McClelland, PharmD
Vice President, Pharmacy Florida Blue
Mike Ochowski, R.Ph. Pharmacy Informatics & EMR Support GHC-SCW
Timothy O’Shea, MS, PharmD Director, Specialty Pharmacy Horizon Blue Cross Blue Shield of New Jersey
Questions? Contact us at MPTrends@PrimeTherapeutics.com.
Introduction
Prime Therapeutics is pleased to present the 15th edition of our Medical Pharmacy Trend Report. Over the past 15 years, advancements in research and technology have grown the medical pharmacy category, leading to surges in approvals for new and more costly treatments. This report presents an analysis of medical benefit drug claims, highlighting key trends and benchmarking insights. It also includes findings from our annual payer survey on strategies for managing drugs under the medical benefit. New this year, we offer an integrated view of pharmacy and medical benefit trends across select therapeutic categories.
15 years of change
2009–2024 trend evolution
Most expensive drug by annual cost: 2009 to 2024
2015 Affordable Care Act (ACA) passed 2010
Zarxio launched first biosimilar
First Remicade biosimilar launched 2016 Kymriah first CAR T-cell therapy on market 2017
2020
Keytruda passes Remicade as top drug by spend
2022-2024
New gene therapy approvals top price charts
Medical pharmacy trend drivers
Overall landscape
The medical pharmacy landscape continued to evolve in 2024 with 29 novel approvals* for medical benefit drugs (down from 39 in 2023).1-3
These approvals accounted for 48% of all novel drug approvals last year. Eleven of the medical benefit drug approvals were for oncology. Two of the highest-cost drugs in history were approved in 2024: gene therapies Lenmeldy ($4.25 million) and Kebilidi ($3.95 million). Drugs that significantly impacted spend trend for the first time in 2024 included Eylea HD, Altuviiio, Briumvi and Vyvgart Hytrulo. In addition to the novel oncology medication approvals, expanded indications for existing oncology drugs continued to drive overall trend across the medical benefit in 2024.
*Novel drugs are drugs with an active ingredient never before approved or marketed. Does not include expanded approvals, line extensions or existing drugs rebranded for a new indication.
2024 utilization trend by annual cost* Figure 2
*Reflects change in utilization of drug and therapy combinations for the various annual cost/utilizer categories shown.
2024 trends Figure 1
Utilization vs. cost contributors
Cost had the greatest influence on overall commercial and Medicare trends, which rose 12.3% and 5.0%, respectively, in 2024. Increased costs were offset by decreased utilization — annual commercial claims volume declined by 6.7%, while Medicare declined by 1.6%. Both utilization (3.9%) and cost (2.1%) played a role in the rising Medicaid trend. Commercial and Medicare saw less utilization for lower-cost therapies (<$100 annual cost per utilizer and $1,000–$10,000 annual cost per utilizer). For therapies with an annual cost per utilizer of $50,000 or greater, utilization rose by 5.0%, 6.1% and 38.7% for commercial, Medicare and Medicaid, respectively.
2024 trend for top 20 drugs* Figure 3
Medical pharmacy trends
Commercial
In 2024, commercial medical pharmacy PMPM costs grew by 4.7%, a significant deceleration compared to 12.5% in 2022 and 12.3% in 2023. This reduction was partially driven by a 6.7% overall utilization decrease — a stark contrast to the prior years’ 11.2% and 12.6% utilization growth rates. However, the average allowed cost per claim rose by 12.3% in 2024 compared to the near-flat trends of 2022 and 2023, which offset some utilization-driven savings.
The top 10 drug therapy categories by PMPM for 2024 remained largely consistent with 2023, accounting for more than 75% of total commercial spend. Oncology continued to dominate, contributing $20.47 PMPM (40.7% of total spend). Vaccines emerged as a new top 10 category entrant, ranking eighth with a PMPM of $0.96, primarily due to increased Prevnar 20 utilization. Within the top 10 categories, colony-stimulating factors (-8.9%) and BDAID: rheumatoid arthritis (-2.4%) saw spend declines due to biosimilar competition. Aside from vaccines, rare disease (12.0%), immune globulins (6.7%) and ophthalmic injections (6.0%) demonstrated the highest PMPM growth rates among the top 10. Outside of the top 10 categories, HIV (40.0%) and hematology: MG (20.4%) had the most growth year over year.
Keytruda remained the leading medication by PMPM at $4.80, which reflects a 10.8% increase from 2023. Darzalex Faspro also had the largest annual trend within the top 10, with a 20.3% increase to $1.26 PMPM. Conversely, several top medications experienced PMPM declines in 2024, including Opdivo (-4.1%), Neulasta (-21.8%), Remicade (-23.5%) and Tysabri (-10.3%).
While reduced utilization tempered PMPM growth, rising perclaim costs and specific high-cost categories continued to shape spending trends.
2023–2024 top drug therapy categories by PMPM spend* Figure 5
2024 oncology vs. oncology support vs. nononcology spend Figure 6
2024 commercial top medical benefit drugs by spend Figure 7
Liquid (immune
2023–2024 commercial components of change* Figure 8
Claims per utilizer Reimbursement Mix Inflation/dosing Utilizers
Keytruda (oncology)
*See glossary on Page 64 for definition of terms. Values under 0.01 not labeled on graph.
Tysabri (MS)
Remicade (Crohn’s/UC)
Gammagard
globulin)
Neulasta (oncology support: GCSF)
Perjeta (oncology)
Darzalex Faspro (oncology)
(Crohn’s/UC)
(MS)
Tysabri (MS)
Remicade (Crohn’s/UC)
Gammagard Liquid (immune globulin)
Neulasta (oncology support: GCSF)
Perjeta (oncology)
Darzalex Faspro (oncology)
Opdivo (oncology)
Entyvio (Crohn’s/UC)
Ocrevus (MS)
2023–2024 top drug therapy categories by PMPM spend Figure 9
Medicare
Medicare’s overall PMPM spend increased 3.4% in 2024 — a marked deceleration from a 16.4% increase in 2023. This trend was primarily driven by a 5.0% increase in cost per claim, which was offset by a 1.6% decrease in utilization. The top 10 spend therapy categories collectively accounted for 84.7% of total Medicare drug expenditure.
Oncology costs reached $46.22 PMPM, representing a 5.2% increase. Most spend in this category was attributed to Keytruda, Opdivo, Darzalex Faspro, Imfinzi and Padcev. In late 2023, Padcev gained approval in combination with Keytruda as the first and only antibody-drug conjugate plus PD-1 to treat advanced bladder cancer. Padcev spend has increased as a result of this expanded indication. Tecentriq was an exception among the top drugs, as PMPM decreased by 22.6% from $2.35 in 2023 to $1.82 in 2024. Tecentriq saw spend and utilization decreases for both respiratory and liver cancers in 2024.
Myasthenia gravis therapy spend declined by 15.8%. Soliris utilizers decreased by 57.4% while newer, lower-cost drugs Vyvgart Hytrulo and Rystiggo entered the market. In ophthalmology, increased utilization of Vabysmo (+54.8%) and decreased utilization of Eylea (-12.8%) continued to affect trend, with Eylea dropping from No. 2 to No. 4 and Vabysmo rising from No. 8 to No. 6 in the past year.
The oncology-support category represented a key trend decrease in Medicare. This multifactorial trend was driven by increased utilization of more affordable biosimilar drugs, and advancement in targeted therapies that have reduced reliance on traditional supportive-care medications. Medicare drug price negotiations under the Inflation Reduction Act are expected to have an impact on spend in future years, as Medicare Part B drugs are due to be included for 2028.
2024 oncology vs. oncology support vs. nononcology spend* Figure 10
2024 Medicare top medical benefit drugs by spend Figure 11
2023–2024 Medicare components of change* Figure 12
Claims per utilizer
Reimbursement Inflation/dosing
Mix
*See glossary on Page 64 for definition of terms. Values under $0.05 not labeled on graph.
2023–2024 top drug therapy categories by PMPM spend Figure 13
Medicaid
Medicaid trend was 6.1%, with a $0.94 PMPM increase from 2023 to 2024. Trend was driven by a 3.9% utilization increase, along with a 2.1% rise in cost. The top 10 drug categories contributed 74.5% of the overall PMPM spend in 2024. Oncology remained the highest spend category, with $6.41 PMPM (+16.7%) in 2024, and accounted for 39.4% of total spend.
Rare disease ($0.73 PMPM; -23.9%) declined from the secondhighest spend category in 2023 to the fourth-highest in 2024 due to a 15.9% utilization decrease. This allowed multiple sclerosis to attain the second-highest spend position in 2024, with $0.90 PMPM (+4.7%). Medicaid trend was offset by a 19.1% spend decrease for BDAIDs: Crohn’s/UC in 2024, driven by a utilization shift from the higher-cost Entyvio ($35,621/utilizer) to the lower-cost Skyrizi ($21,511/utilizer).
Keytruda remained the top drug by spend at $1.60 PMPM (+13.5%). Keytruda received approval for additional indications in 2024, contributing to a 30.7% increase in utilizers. Ocrevus ($0.63 PMPM; +1.7%) and Opdivo ($0.49 PMPM; +34.0%) ranked second and third, respectively, which was driven by increased utilization.
For drugs in the top 10, Rylaze had the largest PMPM trend ($0.44 PMPM; +140.5%), driven by cost per utilizer, followed by Botox ($0.46 PMPM; +35.8%), which was driven by a 38.9% increase in utilizers. New spend for Altuviiio ($0.19 PMPM) drove the increases in antihemophilic therapy, contributing 42.7% to trend in the category. The antihemophilic therapy category trend was also influenced by increased utilization (+7.5%) of Hemlibra, leading to a 14.5% increase in spend in 2024.
BDAID: Crohn’s
2024 Medicaid top medical benefit drugs by spend Figure 15
2023–2024 Medicaid components of change* Figure 16
Claims per utilizer Utilizers Reimbursement Inflation/dosing Mix
*See glossary on Page 64 for definition of terms. Values under $0.05 are not labeled on graph.
Spinraza (rare disease)
Spinraza (rare disease)
Ocrevus (MS)
Ocrevus (MS)
Hemlibra (antihemophilics)
Hemlibra (antihemophilics)
Darzalex Faspro (oncology)
Darzalex Faspro (oncology)
Entyvio (Crohn’s/UC) Entyvio (Crohn’s/UC)
Rylaze (oncology)
Rylaze (oncology)
Botox (toxins)
Botox (toxins)
Opdivo (oncology)
Gammagard Liquid (immune globulin)
Gammagard Liquid (immune globulin)
Keytruda (oncology)
Keytruda (oncology)
+$0.19
Medical benefit categories
Oncology*
Oncology PMPM increased by 5.8% and accounted for 40.7% of commercial spend in 2024. Keytruda was the top drug with 10.8% PMPM growth due to increases in cost (5.8%) and utilizers (5.7%). Darzalex Faspro experienced a 20.3% PMPM increase, with a 13.2% claims volume increase. Padcev PMPM spiked 194%, driven by increased utilizers (+103.1%). All three drugs saw market expansion in 2024, with approvals for mesothelioma, endometrial carcinoma and cervical cancer (Keytruda); transplant-eligible, newly diagnosed multiple myeloma (Darzalex Faspro); and cisplatin-eligible urothelial carcinoma (Padcev).
Medicare oncology PMPM grew by 5.2% and amounted to 55.5% of 2024 spend. Keytruda, the top oncology drug by PMPM, saw a 10.0% PMPM rise due to utilization growth, while cost remained relatively flat. Darzalex Faspro (+20.0% utilizers) continued to take over the market share from Darzalex (-44.9% utilizers). Padcev experienced a 101.2% PMPM jump due to 127.9% more utilizers.
For Medicaid, oncology PMPM grew by 16.7% in 2024, driven by increased utilization, and made up 39.4% of spend. Keytruda was the top drug, driven by a 30.7% increase in utilizers. Rylaze saw a 55.8% claims volume increase, along with a 54.3% spike in cost per claim. Rylaze’s cost per claim is impacted by variable dosing based on body surface area. Darzalex Faspro (+86.2%) and Opdivo (+49.8%) both experienced increased utilization.
*Does not include oncology-support drugs such as antiemetics, colony-stimulating factors, gastrointestinal: chemoprotectants and erythropoiesis-stimulating
**Forecasted trends are shown for 2025 forward. ***Due to rounding, totals may not add up accurately.
Figure 22
Commercial deep dive
Multiple myeloma
Multiple myeloma accounted for 9% of commercial oncology spend in 2024, with an 11.5% increase from 2023 ($1.60 to $1.78). Darzalex Faspro/Darzalex and Kyprolis are the standard of care in multiple myeloma and remained spend drivers in 2024. Higher-cost bispecific antibodies and CAR T-cell therapies also contributed to the increase in spend.
Darzalex Faspro saw a 20.4% rise in PMPM ($0.94 to $1.13) and utilizers (+15.8%) from 2023 to 2024. This SQ formulation has a shorter infusion time (3 to 5 minutes) and continues to take market share from IV Darzalex.
Bispecific antibodies Tecvayli and Talvey, indicated for relapsed or refractory multiple myeloma after four prior lines of treatment, are ranked 6 and 10 in multiple myeloma spend. These drugs have response rates comparable to CAR T-cell therapy and offer an off-the-shelf treatment option. Talvey saw a modest $0.02 (+261.8%) PMPM increase, driven by a rise in utilizers (+277.3%) and claims (+503.4%). Tecvayli and Talvey were both approved under the accelerated approval process; their continued use depends on confirmatory trial outcomes.
In early 2024, Carvykti received an updated indication to be used as second-line treatment based on results from the CARTITUDE-4 trial. Carvykti saw a 47.0% claim increase, resulting in a 34.2% PMPM increase ($0.02 to $0.03). There are now additional qualified treatment centers available to administer Carvykti. This, along with the expanded indication, may influence future spend and utilization.
to rounding, totals may
Tecvayli Sarclisa
Xgeva/ Prolia
Darzalex
Kyprolis
Darzalex Faspro
Medicare deep dive
Female reproductive cancer*
Comprising only 6% of Medicare oncology spend in 2024, female reproductive cancer saw a 87% PMPM trend increase to $2.68 (+$1.25) in 2024, driven by increased utilization (+39.0%) and annual costs per utilizer (+38.9%). Three drugs — Keytruda, Jemperli and Elahere — contributed more than 80% of the PMPM costs ($1.61, $0.32 and $0.30, respectively).
Keytruda remained the top drug with a 55.7% utilizer increase. In mid-2024, Keytruda received an expanded indication approval for use in primary advanced or recurrent disease in combination with carboplatin and paclitaxel for endometrial carcinoma. The NCCN guidelines adopted this regimen as a Category 1 recommendation.
Elahere contributed 16.7% to trend with a $0.24 PMPM increase from 2023 due to growth in both utilization (+56.5%) and cost per claim (+53.3%). Elahere’s indication for folate-α (FRα)-positive, platinum-resistant epithelial ovarian, fallopian tube or primary peritoneal cancer with prior systemic treatment regimen(s) converted to full approval in early 2024.
Jemperli contributed 16.0% to trend with a $0.23 PMPM increase in 2024, driven by a 158.3% utilization increase. Jemperli received NCCN Category 1 placement as a preferred triplet combination therapy option for endometrial carcinoma.4
Bevacizumab biosimilars Mvasi and Zirabev saw minor PMPM decreases ($0.03 and $0.02, respectively) due to lower costs. Vegzelma saw new spend at $0.04 PMPM and contributed 2% of this cancer type’s spend. Top oncology spend by cancer type Figure 24
*Female reproductive cancers include cancers of the cervix, endometrium, fallopian tube, ovary, uterus, vagina and vulva. **Due to rounding, totals may not add up accurately.
***See glossary on Page 64 for definition of terms.
Vegzelma Zirabev Mvasi Elahere Jemperli Keytruda
oncology spend by cancer type Figure 27
Medicaid deep dive
Gastrointestinal cancer
Gastrointestinal (GI) cancer drove Medicaid’s 16.7% oncology spend increase in 2024, accounting for 13.1% of oncology spend. Compared to 2023, GI cancer spend grew by $0.32 PMPM (60.6%), from $0.52 to $0.84, making it a top trend contributor in the oncology space. This increase was driven by a $241 (13.4%) cost-per-claim rise, 38.0% utilizer growth and a 41.7% claims volume increase.
Immune checkpoint inhibitors (ICIs) were four of the top five highest-spend GI cancer drugs in 2024, collectively making up 61.8% of GI cancer spend. All top ICIs experienced a PMPM increase in 2024 (90.5% Keytruda, 84.8% Imfinzi, 62.1% Opdivo, 35.0% Tecentriq). Notably, Yervoy experienced the greatest PMPM increase (185.1%) of the top 10 GI cancer drugs.
Growing from $0.09 to $0.18 PMPM, Keytruda became the highest-spend GI cancer drug in 2024. Keytruda’s PMPM spend growth outpaced Opdivo, which topped the GI cancer category in 2023. Though Keytruda’s cost per claim fell by 5.4%, it was offset by increases in utilizers (+126.4%) and claims volume (+101.4%). Keytruda’s spend increase was driven by two label expansions in late 2023: It was approved for the treatment of locally advanced unresectable or metastatic biliary tract cancer in combination with gemcitabine and cisplatin, and for firstline treatment of adults with locally advanced unresectable or metastatic HER2-negative gastric or gastroesophageal junction adenocarcinoma in combination with fluoropyrimidine- and platinumcontaining chemotherapy.
2023–2024 GI Medicaid components of change** Figure 29
Rare disease*
Rare disease PMPM trend increased for commercial and Medicare, but decreased for Medicaid in 2024. Tepezza, which amounted to $0.69 out of $1.60 total PMPM in the class, was the major contributor to commercial spend. Medicare rare disease spend was $2.38 PMPM, largely driven by Reblozyl ($1.33 PMPM), Tepezza ($0.71 PMPM), Amvuttra ($0.28 PMPM) and Spinraza ($0.28 PMPM). Medicaid spend was $1.01 PMPM, driven by Tepezza ($0.25 PMPM) and Vyondys 53 ($0.22 PMPM). Reblozyl and Tepezza were in the top five drugs by spend across all LOBs. In the second half of 2023, Reblozyl was approved for first-line treatment of anemia in adults with lower-risk myelodysplastic syndromes who may require transfusions, likely contributed to its increased utilization.
For commercial, Gamifant, Spinraza and Exondys 51 saw the most significant reduction in PMPM spend. Onpattro and Givlaari decreased Medicare spend; Elevidys and Gamifant lessened Medicaid spend. While total spend percentage and PMPM can be low for medications used to treat rare diseases, their cost per utilizer can be significant. Annual average cost per utilizer was $461,233 for commercial, $149,340 for Medicare and $257,153 for Medicaid.
Forecasts project continued growth at a rate of 276.8% in commercial, 148.3% in Medicare and 1122.9% in Medicaid over the next three years. Elevidys is predicted to have a significant impact on trend given its $3.2M price tag. Pipeline therapies for Duchenne muscular dystrophy and spinal muscular atrophy are also projected to increase trend over the next few years.
2023–2024 PMPM trend*** Figure 31
2024 % of medical drug spend Figure 33
2020–2027 PMPM trends and forecast** Figure 34
Hematology*
The hematology therapy category encompasses multiple disease states, including myasthenia gravis (MG), paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic uremic syndrome (aHUS), among others.
For the commercial LOB, total PMPM spend was $1.55, an increase of 6.5% from $1.46 in 2023. The MG subcategory was the contributor to trend, with spend increasing by 20.4%. Decreases in PNH spend (-16.6%) dampened hematology trend.
Our analysis indicates that health plans are supporting shifts to lower-cost alternatives in place of Soliris. For MG, Soliris utilizers declined by 29.8%, while Vyvgart utilizers rose by 4.6% in 2024. Annual cost per utilizer was $450,822 and $226,733, respectively. There was also new spend for Vyvgart Hytrulo, which cost $191,482 per utilizer, and Rystiggo, which cost $190,068 per utilizer.
Hematology PMPM spend decreased by 11.0% and 22.3% in Medicare and Medicaid, respectively. In Medicare, Vyvgart spend for MG decreased by $0.21 PMPM from 2023 to 2024, driven by decreased utilization. There was a shift from Soliris ($0.61 to $0.30 PMPM) to Ultomiris ($0.29 to $0.49 PMPM) for MG.
For Medicaid, PMPM increased from $0.03 to $0.12 for Ultomiris for PNH, driven by utilization in 2024. All other hematology drugs had spend PMPM decreases driven by decreased utilization.
2023–2024 PMPM trend*** Figure 35
2024 % of medical drug spend Figure 37
*Hematology drugs included in this report are
Rituximab products were only included when used for hematologic indications.
**Forecasted trends are shown for 2025 and forward.
***Due to rounding, totals may not add up accurately.
Immune globulin therapy remained a top 10 spend category for all LOBs, representing 6.0% of commercial, 4.3% of Medicare and 4.1% of Medicaid total spend.
Spend increased due to utilization demand despite cost decreases. Panzyga had a PMPM spend resurgence (+53.9% commercial, +16.4% Medicare, +20.7% Medicaid) with a recent expanded indication to treat chronic inflammatory demyelinating polyneuropathy.
Commercial had the highest cost per claim at $3,999 (-1.6% from 2023). Xembify had a spend increase of 75.8%, driven by increases in cost per claim (+23.0%) and utilizers (+54.4%). Gammagard remained the top spend drug at $0.83 PMPM, up 7.9% from 2023. Forecasts predict the commercial sector will experience the largest PMPM growth (+33.8%) over the next three years.
Medicare PMPM increased from $3.46 to $3.58 in 2024 (+3.5%), largely due to an 11.3% utilizer increase. Cuvitru had a spend increase of 182.6% ($0.07 PMPM), driven by utilization and claims volume. Hizentra (-23.0%) and Hyqvia (-29.0%) had impactful spend decreases due to utilization.
Medicaid trend remained flat as decreased cost per claim (-21.2%) offset a 27.4% utilizer increase. Gamunex-C/Gammaked contributed 7.6% to the trend, driven by additional utilization (+68.2%). Octagam utilization continued to decrease (-28.3%), leading to a 43.7% spend decrease.
2023–2024 PMPM trend*** Figure 39
2024 % of medical drug spend Figure 41
*Immune globulin in this section excludes RH0 [D] immune globulin. **Forecasted trends are shown for 2025 forward. ***Due
Vaccines
While total vaccine drug spend remained relatively low in 2024, clinical guideline changes produced utilization shifts across all LOBs.
Medicare was the only LOB to see a decline in vaccine spending, dropping 11.7% to $1.00 PMPM. This reduction was largely driven by a 15.1% drop in claims, only partially offset by a 3.9% rise in cost. The primary dampener was Prevnar 20, which saw a 29.3% utilizer decrease in contrast to 2023’s significant growth.
In contrast, commercial vaccine spend increased 73.2% to $0.96 PMPM due to increased utilization (+45.2%) and cost (+19.3%).
Prevnar 20 contributed 53.7% of PMPM trend, which was driven by the Advisory Committee on Immunization Practices’ October 2024 recommendation to lower administration age from 65 to 50. Beyfortus’ utilization increased 261.0% while Synagis fell by 55.1%, a trend supported by emerging studies favoring Beyfortus’ longer-lasting antibody protection5 and singular seasonal dosing schedule.
Though Medicaid vaccine spend remained comparatively low at $0.28 PMPM, it represented an 82.4% increase over 2023 driven by rising utilization. Utilizers grew by 149.2%, with costs falling 44.3%. Medicaid spend was driven by Prevnar 20 ($0.16 PMPM), followed by COVID-19 vaccines. RSV vaccines also drove trend, where Abrysvo utilizers increased by 833.9% and Arexvy by 162.4% following their expanded indication for adults ages 50–59 at heightened risk of disease. 2020–2027 PMPM
2023–2024 PMPM trend** Figure 43
2024 % of medical drug spend Figure 45
2020–2027 PMPM trends and forecast** Figure 46
Biologic drugs for autoimmune disorders*
The biologic drugs for autoimmune disorders (BDAIDs) category accounted for 13.4% of spend in the commercial line of business for 2024. Both the Crohn’s/UC and the rheumatiod arthritis subcategories placed in the top 10 categories for commercial. Overall BDAID spend only grew by 2.0%, driven by Skyrizi (+109.1%) and Saphnelo (75.4%). An increasing shift to biosimilars, which lowered costs and utilization for Remicade and Rituxan, including decreasing ASP for the reference product, helped offset spend.
An 11.6% PMPM trend in Medicare largely stemmed from increased spend and utilization in the Crohn’s disease and ulcerative colitis category. In contrast to the commercial LOB, Entyvio and Stelara SQ utilization trended higher in the Medicare LOB in 2024.
For Medicaid, overall BDAID trend decreased by 2.1%. Utilization increased significantly (+56.5%) in the rheumatoid arthritis category, which was offset by decreased BDAID spend (-19.1%) for Crohn’s and ulcerative colitis. In 2024, Medicaid cost per claim dropped by 20.3%, driven by decreases for Entyvio (-7.4%) and Benlysta IV (-6.5%). Cost-per-claim decreases for Benlysta IV were offset by an 18.7% increase in claims, leading to increased spend.
2023–2024 PMPM trend*** Figure 47
2024 % of medical drug spend Figure 49
*Autoimmune disorders in this section include ankylosing spondylitis, Crohn’s
**Forecasted trends are shown for 2025 forward.
***Due to rounding, totals may not add up accurately.
BDAIDs deep dive
Commercial
In the Crohn’s disease and ulcerative colitis category, Entyvio remained a top spend drug with a $2.11 to $2.13 PMPM increase in 2024, although the trend is starting to level out compared to the previous three years. Decreased utilization was slightly offset by cost per utilizer, ultimately leading to a modest PMPM increase. This may reflect a shift from the IV to the SC formulation, which was approved in September 2023. Skyrizi, which received an expanded indication for ulcerative colitis in June 2024, was another trend driver that experienced a PMPM increase from $0.18 to $0.37, largely driven by a utilization increase.
The trend dampener primarily includes Remicade, whose allowed PMPM trend decreased from $1.02 to $0.78 as the market share continued to shift to infliximab biosimilars, which is continued from the 2022–2023 trends.
Medicare
In 2024, Crohn’s disease and ulcerative colitis spend increased to $1.53 from $1.22 in 2023 (+25.7%), driven by utilization and cost increases. Entyvio PMPM spend increased 28.1% to $1.05, and utilizers increased by 12.7%. Medicare showed the highest Entyvio trend increase compared to commercial and Medicaid, which may reflect a hesitation to transition to the self-administered Entyvio SQ formulation in this population.
(Continued on the next page.)
Crohn’s/UC
BDAIDs deep dive (continued)
Trend increased modestly by 4.9% within the rheumatoid arthritis category, which was largely driven by Orencia and Actemra. Orencia PMPM spend rose by 10.9% with an increase in claims volume, becoming a more common option in the Medicare population. Actemra trend also increased, primarily due to a rise in utilizers and claims volume.
Medicaid
Crohn’s disease and ulcerative colitis saw a $0.16 PMPM decrease from 2023, which was largely driven by reductions in Entyvio, Remicade and Inflectra spend. Entyvio PMPM fell 19.1% from 2023 as a result of lower utilization and cost. The decrease from Entyvio IV was most apparent within the Medicaid LOB, which may reflect a shift to the SQ formulation in this patient population. Both Remicade and Inflectra spend decreased in 2024, and Inflectra’s 29.7% increase in utilizers was largely offset by a lower cost per claim. Remicade utilization continued to fall across all LOBs.
Within the rheumatoid arthritis category, Actemra and Orencia contributed to a $0.08 PMPM trend increase. Both gained utilizers and experienced a rise in claims volume. The impact of the Actemra biosimilars in this class will be worth monitoring in the coming years.
Commercial Crohn’s/UC: Top PMPM spend drugs* Figure 51
Ocrevus remained the top drug in this category across all LOBs, followed by Tysabri and Briumvi. Commercial and Medicaid saw relatively stable Ocrevus utilization and spend from 2023 to 2024; however, Medicare saw a 28.6% PMPM decrease from $1.20 to $0.86, resulting from a decrease in Ocrevus utilizers (-23.9%). Commercial Ocrevus spend went from $2.88 in 2023 to $2.89 PMPM in 2024, and Medicaid spend rose from $0.62 to $0.63 PMPM.
Tysabri saw spend decreases in all LOBs. Utilizers decreased by 7.6% and 23.5% in commercial and Medicare, while cost per claim (-18.7%) dampened Medicaid spend.
Briumvi spend increased across all LOBs, most significantly in commercial, where PMPM increased from $0.03 to $0.14, driven by a 209.8% increase in utilizers. Briumvi was approved in December 2022 and launched in Q1 2023. It is the third CD20 inhibitor approved after Ocrevus and Kesimpta. Increasing utilization for Briumvi could be driven by provider preference, shorter infusion time (one hour versus two hours for Ocrevus), lower WAC, and the fact that postinfusion monitoring is at physician discretion after the first two infusions, while observation continues throughout Ocrevus treatment. Rituximab products, once popular off-label options, saw negligible spend across all LOBs with the approval of these newer therapies. Looking forward, Tyruko, the first Tysabri biosimilar, was approved in 2023 and is expected to launch in Q4 2025, which will further impact this category with decreased costs.
The oncology support: granulocyte colonystimulating factor (GCSF) category remained among the top 10 spend categories for commercial (No. 5) and Medicare (No. 10) in 2024. Commercial PMPM spend decreased by 8.9%, from $1.52 in 2023 to $1.38 in 2024, due to utilization and cost decreases. Neulasta fell from the fifth-ranked drug by PMPM spend for the commercial LOB in 2023 to the seventhranked drug in 2024 on the heels of a $0.24 PMPM (-21.8%) spend decrease. For Medicare, the trend remained flat ($0.01 PMPM). Similar to 2023, GCSF drugs were not in the top 10 list for Medicare. Medicaid trend decreased by 33.7% to $0.23 PMPM in 2024. The continued use of biosimilars contributed to the trend decrease in this category.
In commercial, Udenyca and Fulphila saw the largest spend increases due to higher utilization; from $0.14 PMPM in 2023 to $0.25 PMPM in 2024 for Udenyca and $0.18 PMPM to $0.20 PMPM for Fulphila. Neulasta had the largest spend decrease at 21.8%. The story is similar for Medicare, where Udenyca, Stimufend and Fulphila had the largest spend increases, again due to higher utilization; from $0.14 in 2023 to $0.29 PMPM for Udenyca, $0.02 to $0.11 PMPM for Stimufend and $0.20 to $0.26 PMPM for Fulphila. Neulasta spend decreased by 40.6% to $0.40 PMPM. Fulphila spend nearly doubled in Medicaid ($0.05 PMPM to $0.09 PMPM) while all other products saw decreased spend and utilization.
2023–2024 PMPM trend** Figure 59
2024 % of medical drug spend Figure 61
2020–2027 PMPM trends and forecast Figure 62
Ophthalmic injections
The ophthalmic injections category, dominated by anti-vascular endothelial growth factor (VEGF) drugs, continued to drive PMPM trends within the commercial and Medicare LOBs. Commercial experienced a $0.05 PMPM increase and a 6.0% rise in spending, primarily due to higher Vabysmo utilization (+83.0%). Medicare saw a slight PMPM decrease ($0.06) driven by lower utilization. While Eylea remained the top-spend drug in this category, its PMPM declined in both LOBs due to a claims-volume decrease (~12%), which was offset by utilization increases for Vabysmo. Newer to the market, Eylea HD had a $0.07 PMPM for the commercial LOB. For Medicare, the downward trend was offset by Eylea HD at $0.33 PMPM, and Syfovre, a complement inhibitor for geographic atrophy, at $0.40 PMPM.
Due to pricing and dosage form limitations, ranibizumab biosimilars did not reduce costs as seen in other categories with biosimilars. The launch of aflibercept biosimilars is also not expected to be as competitive as compounded bevacizumab (Avastin). The utilization frequency of treat-and-extend products was expected to decrease costs through fewer claims per utilizer; however, PMPM increased 6.0% in the commercial LOB. We anticipate costs increasing as Eylea, Eylea HD and Vabysmo make up the majority of market share after Avastin for wet AMD and diabetic macular edema. Despite ongoing shortage challenges, compounded bevacizumab (Avastin) remains the most costeffective first-line drug for the Medicare VEGF therapeutic class, with a stable PMPM of $0.35.
2023–2024 PMPM trend** Figure 63
2024 % of medical drug spend Figure 65
Biosimilar trends*
Across all LOBs, biosimilar market shares continued to increase for almost all categories, while biosimilar cost per claim continued to decrease. This led to significant cost-per-utilizer decreases for most categories, most notably in Medicaid, where many categories saw a more than 30% decrease from the previous year.
Ranibizumab
Cimerli experienced rapid uptake, reaching 50% market share in commercial, 72% in Medicare and 90% in Medicaid. However, due to a 35% drop in ASP in 2024, Cimerli production will pause in 2025.
Pegfilgrastim
Neulasta’s market share continued to decrease across all LOBs. Neulasta is still a top 10 drug by spend for commercial, but no longer for Medicaid and Medicare. Across all LOBs, Fulphila continued to gain significant market share, Udenyca saw modest gains, and Ziextenzo dropped below 1% due to availability issues.
Rituximab
In commercial and Medicare, Rituxan market share continued to slowly erode while biosimilars increased modestly. In Medicaid, Rituxan gained significant share, Truxima lost market share and other products stayed largely consistent.
Trastuzumab
Across all LOBs, Herceptin market share remained stable below 10%, while Ogivri share continued to steadily increase.
Trastuzumab commercial market share
Figure 69
Lucentis Byooviz Cimerli
Rituxan Rituxan Hycela
Integrated data
For this year’s report, we developed and incorporated a new crossbenefit analysis with membership distinct from the rest of the report. This population includes membership for which claims data is provided across both medical and pharmacy benefit types. This integrated view, which consists of claims data from 2023 and 2024, allows the reader to observe drug trends in a holistic manner. As Prime’s integrated specialty capabilities expand, we expect to provide a more robust analysis in future publications.
Top 11.5% of members accounted for 91% of cost
Spend distribution of commercial population Figure 70
At a glance
2024 membership: 17.3M commercial 1.1M Medicare
Ocrevus spend 2X any other MS drug
Keytruda top oncology drug
Commercial immune globulin spend on medical benefit 92.8%
Spend by benefit type Figure 71
Integrated multiple sclerosis
Commercial
The total PMPM for the multiple sclerosis category decreased from $5.88 in 2023 to $5.75 in 2024 (-2.3%). Older therapies such as Rebif and Avonex had decreases in spend due to decreased utilization. Significant decreases in spend were seen for branded products Aubagio, Gilenya and Tecfidera as members shifted to generics. There was also an increase in utilizers for newer, high-efficacy therapies on the pharmacy benefit. Kesimpta, Vumerity, Zeposia and Tascenso all saw increased utilizers in 2024. On the medical benefit, Briumvi had the largest utilization increase (+219%) from 2023. Ocrevus continued to see a modest increase in utilization and PMPM, from $2.19 to $2.28, and a 3% increase in utilizers.
Kesimpta added the largest contribution to PMPM trend (5.3%) with an increase in PMPM from $0.68 to $0.99 between 2023 to 2024. Briumvi PMPM rose from $0.04 to $0.15, an increase of 298%. Tascenso ODT had a modest PMPM increase ($0.01 to $0.02) because overall utilization increased 38%, along with claims per utilizer (91%), after the drug entered the market in February 2023. Tascenso’s launch allowed patients taking fingolimod and Gilenya to switch to Tascenso and continue to receive patient support services that were being discontinued for other fingolimod products.6
Top 10 drugs by combined medical and pharmacy PMPM spend** Figure 73
Spend by benefit type Figure 74
Integrated multiple sclerosis Medicare
The PMPM spend for the multiple sclerosis category fell from $4.32 in 2023 to $4.13 in 2024. Similar to commercial, this decline was driven by decreases in spend and utilization for the branded oral products Aubagio, Gilenya and Tecfidera. There was evidence of some shift to lower-cost generic products, specifically to fingolimod and teriflunomide where utilization increased by 18% and 28%, respectively.
Ocrevus was the top PMPM driver ($1.19 to $1.34), followed by Kesimpta ($0.36 to $0.41).
Older products, such as Avonex, Copaxone/ Glatiramer and Tysabri, were in the top seven PMPM spend among Medicare membership, highlighting a population that may have longterm stability on these products. Briumvi, Zeposia, Ocrevus and teriflunomide had the top increases in utilizers.
In Medicare, a few drugs had spend on both the pharmacy and medical benefits, which differed from commercial where drugs were processed on one benefit or the other. Briumvi, Tysabri and Ocrevus had 9.5%, 6.9% and 10% pharmacy utilization in Medicare, respectively.
Cost per claim* Figure 75
Top 10 drugs by combined medical and pharmacy PMPM spend** Figure 76
Spend by benefit type Figure 77
Integrated immune globulin
Commercial
Immune globulin combined medical and pharmacy PMPM spend increased 9.1%, from $2.76 in 2023 to $3.01 in 2024. The spend split was 92.8% on the medical benefit and 7.2% on the pharmacy benefit. Gammagard was the top spend drug in 2024 at $0.74 PMPM, of which 97.9% was billed to the medical benefit.
Hyqvia and Hizentra, which are given SQ and can be self-administered, had the most evenly distributed spend split across both benefits (66% medical/34% pharmacy and 65% medical/35% pharmacy, respectively).
Cuvitru was the only other drug in the top 10 with more than a nominal portion of spend on the pharmacy benefit. Medical benefit spend was 81.5% and pharmacy benefit spend was 18.5%.
Another SCIG product, Xembify, ranked 12th by PMPM spend and was split 87.3% on the medical benefit and 12.7% on the pharmacy benefit.
Asceniv had the highest per-claim cost in the immune globulin category at $48,664 per claim in 2024, which was 10 times the cost of most other IVIG products. Asceniv is produced by blending plasma from hyperimmune donors who have RSV antibodies with normal source plasma, leading to its high cost. Even with low utilization, Asceniv rounded out the top 10 drugs by spend due to high cost. This provides clear opportunity for clinical management opportunities with this medication.
Top 10 drugs by combined medical and pharmacy PMPM spend** Figure 79
Spend by benefit type Figure 80
Integrated immune globulin Medicare
The distribution of immune globulin products in Medicare was markedly different than in commercial. In Medicare, as opposed to commercial, spend skewed toward the pharmacy benefit. Medicare will cover IVIG under Part D (pharmacy benefit) if treating an FDA-approved diagnosis that is not covered under Part B (medical benefit). Medicare-covered FDAapproved indications for IVIG include primary immunodeficiency and chronic inflammatory demyelinating polyneuropathy (CIDP). Similar to commercial, Gammagard was the top drug by PMPM spend at $2.50, up 11.6% from $2.24 in 2023. Spend for this drug was split 46.2% on the medical benefit and 53.8% on the pharmacy benefit.
Of the top 10 products by PMPM spend, only two had 5% or less spend on the medical benefit: Gammaplex and Gammaked. Cuvitru had the largest spend increase from 2023 to 2024 at 92.6% due to increased utilization. Gammaplex (+48.4% PMPM) and Octagam (+47.1% PMPM) also saw a higher PMPM spend as a result of utilization increases.
Gammaked had the highest cost per claim in 2024 at $12,115, which was a 25.7% increase from 2023. Gammaplex (-6.1%) and Cuvitru (-5.0%) were the only drugs in the top 10 to have decreases in cost per claim year over year.
Cost per claim* Figure 81
Top 10 drugs by combined medical and pharmacy PMPM spend** Figure 82
Spend by benefit type Figure 83
Integrated oncology
Commercial
Oncology was a key spend driver on both the pharmacy and medical benefits. Overall oncology spend was $35.19 PMPM in 2024, an increase of 11.6% from a PMPM of $31.51 in 2023. Spend on the medical benefit accounted for 59.5% of the overall spend. The same 60/40 distribution can be seen in the top 10 drugs, where six products were medical benefit drugs and four were on the pharmacy benefit.
Within the integrated data, Keytruda ($4.80 PMPM) and Opdivo ($1.55 PMPM) were the top drugs by medical benefit PMPM spend. The top pharmacy benefit drugs were Verzenio, with $1.32 PMPM, and Revlimid, with $0.83 PMPM. Medications with breast cancer indications made up half of the top 10 drugs. Keytruda is indicated for triple negative breast cancer, the CDK4/6 inhibitors Verzenio and Ibrance are indicated for HR+/HER2- breast cancer, and Perjeta and Enhertu are indicated for HER2+ disease. Enhertu spend increased by 23.4%, from $0.56 to $0.70, due to an expanded indication for HER2low breast cancer. Verzenio spend increased from $1.10 in 2023 to $1.32 in 2024 (+20.2%), while Ibrance spend decreased by 21.4%, from $0.82 to $0.64. Another CDK 4/6 inhibitor, Kisqali (No. 11), saw an 87.9% spend increase, from $0.33 to $0.61 PMPM. Both Verzenio and Kisqali have Category 1 NCCN recommendations for multiple treatment scenarios, leading to increased utilization of both drugs, whereas Ibrance has a category 2A recommendation in most cases.7
Top 10 drugs by combined medical and pharmacy PMPM spend** Figure 85
Integrated oncology Medicare
In the integrated Medicare data, overall oncology spend increased by 29.8% between 2023 and 2024, from $80.11 to $104.00 PMPM. Spend on the medical benefit accounted for 53.9% of the overall spend, although only three of the top 10 drugs are on the medical benefit (Keytruda, Darzalex Faspro and Opdivo). Keytruda ($14.81 PMPM) and Revlimid ($7.00 PMPM) were the top drugs by PMPM spend, and Keytruda’s spend was more than double Revlimid’s. Total oncology drug utilizers increased by 11.3% in 2024.
The top 10 drugs by spend are predominantly treatments for multiple myeloma and leukemia/ lymphoma. Brukinsa, the ninth-ranked drug, saw the greatest spend increase (170%), rising from $0.95 PMPM in 2023 to $2.56 PMPM in 2024. Imbruvica, another Bruton tyrosine kinase inhibitor with similar labeled indications as Brukinsa, had the lowest year-over-year increase (5.3%) of all the top 10 drugs, increasing from $2.32 to $2.44 PMPM in 2024. Notably, Imbruvica has been selected as one of the first 10 drugs for price negotiations under the Inflation Reduction Act.8 The negotiation process used prices from 2023 to determine a maximum fair price of $9,319 per 30-day supply, which will begin in calendar year 2026. As more drugs become subject to these price negotiations, we anticipate shifting trends in the Medicare space. Spend by benefit type Figure 86
Top 10 drugs by combined medical and pharmacy PMPM spend** Figure 88
Payer survey
Respondent sample Figure 89
28
Payers (19 with Medicare lives; 14 with Medicaid lives)
Respondent plan size Figure 90
47.2M
Medical pharmacy lives (national, regional and local/state)
Geographic dispersion of lives Figure 91
89%
Pharmacy directors, VPs, chief pharmacy officers
11%
Clinical managers, clinical analytics
General management
Most organizations (82%) review reimbursements across medical and pharmacy benefits to determine the most cost-effective coverage benefit. The same percentage of plans currently monitor medical and pharmacy claims for duplicates. For plans that don’t, the biggest challenges are benefits administered by different insurers and lack of resources.
Eighty-six percent of plans allow white bagging of medical specialty drugs. White bagging is a management strategy in which the cost of the drug is billed on the pharmacy benefit and the medication is shipped from the specialty pharmacy directly to the provider’s office for administration.
Value-based contracts (VBCs)/outcomes-based agreements (OBAs) are a key tool for managing high-cost specialty medications, especially in the gene and cell therapy space. About two-thirds of plans (68%) indicated they enter VBCs/OBAs as a management strategy. A majority of plans (84%) indicated that the most important aspect of the VBC/OBA is cost reduction if clinical outcomes are not achieved.
Plans were surveyed about other management strategies, including the ability to manage drugs that fall under the same HCPCS code and using foundation funding to offset costs. Most health plans (89%) require, or would be interested in requiring, providers to submit National Drug Codes for drugs that share HCPCS codes. Only 14% of health plans surveyed contract with a third party that ensures members use patient assistance programs or foundation funding prior to covering medical drugs.
Cross-benefit review to identify most costeffective coverage benefit Figure 92
Monitoring medical and pharmacy claims for duplicates Figure 93
Allow white bagging Figure 94
Gene therapy
Gene therapy continued to be a hot topic in the industry due to its high financial impact. With the potential financial risk, only 8% of plans excluded all FDA-approved gene therapies, while another 40% excluded some products. Top reasons for exclusion were a lack of clinical evidence (59%) and affordability (33%).
Plans used a variety of strategies to project a gene therapy claim’s risk (Figure 98). Plans managed the financial impact of gene therapy claims with prior authorization, reinsurance/ stop-loss/risk carve-out, VBCs/OBAs, contract negotiation services, warranty services and installment payment plans.
Outcomes monitoring continued to be a challenge for plans — just over half of plans monitored outcomes for some (32%) or all (24%) gene therapies covered by their organization. For plans that tracked outcomes, internal tracking methods using claims data and medical records were utilized most often. Across all plans surveyed, lack of staff/infrastructure (40%) was the largest barrier to outcomes tracking, followed by tracking outcomes across coverage (24%).
Plans identified managing financial risk (72%) as the largest challenge surrounding gene therapy. Plans identified coordination with other care teams (28%) as the largest gap in the patient-care journey. Solutions for improving the patient-care journey included dedicated case management, financial assistance programs, third-party solutions, concierge/support programs, and disease-state specific organization or advocacygroup partnerships.
Oncology
Emerging research has demonstrated the feasibility of giving CAR T-cell therapy in an outpatient setting rather than in a hospital; however, only 30% of payers surveyed said they have seen this shift. Multiple CAR T-cell therapies are now approved as earlier lines of therapy. Only 3% of respondents preferred one CAR T-cell therapy over another, although 44% said they are considering a future strategy. Less than half of plans (41%) were monitoring covered CAR T-cell therapy outcomes. Lack of staff/infrastructure was the largest barrier to outcomes tracking.
Plans also employed a variety of strategies to manage oncology biosimilars (Figure 105). Cost (89%) was the overwhelming reason for selecting the strategy. Another emerging trend was the approval of SQ drug formulations that were previously only available for IV administration, with 74% of plans already considering strategies in this space.
Many plans (52%) have or are implementing regimen-based reviews for oncology drugs, most commonly via an external vendor (64%). Medical and pharmacy benefits being managed by different vendors presented the greatest challenge to regimen-based reviews. Most plans (78%) surveyed did not cover oral oncology drugs on the medical benefit when used as part of a combined oral and IV regimen. Despite this, 81% of plans would be interested in monitoring oncology treatment with integrated medical and pharmacy reporting, presenting an advanced opportunity for better management of this category.
Largest barrier for outcomes tracking Figure 104
Top concerns for SQ formulation Figure 106
Accelerated approval
Accelerated-approval drugs are those granted approval through the FDA’s Accelerated Approval (AA) Program, requiring additional trials to confirm and further define their clinical benefit. Health plans must decide if they are going to cover drugs that may ultimately prove to have no clinical benefit. Management strategies include covering all AA drugs, excluding all AA drugs or excluding some AA drugs. In our survey, only one of 23 respondents indicated they exclude some AA drugs solely based on AA pathway approval.
As of Dec. 31, 2024, there have been 328 drug and indication approvals via the AA Program. There have been 26 application withdrawals and 21 indication withdrawals. In oncology, 31 of 205 approvals have been withdrawn. There is an opportunity for strategic management to ensure use for patients who have limited or no alternative treatment options. Regarding handling existing prior authorizations if approval is withdrawn due to lack of clinical benefit in a confirmatory trial, half of plans term the existing authorization concurrent with the date of the AA withdrawal, while another 40% allow the authorization to remain active until the original expiration date.
Almost half (48%) of plans were unsure whether they found the AA pathway valuable for care access due to uncertainty. When evaluating management strategies for AA drugs, 53% of plans said they would find real-world efficacy and safety the most valuable aspect of real-world evidence (RWE). Exclude drug solely based on AA status Figure 108
2024
2023–2024 commercial top 25 PMPM spend Figure 116
3
This year’s report includes drivers and dampeners. *Trend-driver rank is based on total change from 2023–2024.
2023–2024 Medicare top 25 drug PMPM spend Figure 117
This year’s report includes drivers and dampeners. *Trend-driver rank is based on total change from 2023–2024.
2023–2024
Medicaid top 25 drug PMPM spend Figure 118
This year’s report includes drivers and dampeners. *Trend-driver rank is based on total change from 2023–2024.
2024 top 10 highest-cost medical benefit drugs by allowed amount per utilizer* Figure 119
$3,220,000
$2,781,000
$2,189,000
$1,963,000 $1,953,000
*The above drugs are approved for conditions that fall into the following categories: antihemophilics, rare diseases, hereditary angioedema, enzyme replacement therapy, oncology and hematology. Drugs administered in the hospital inpatient setting are not included in analyses. Annual allowed cost per utilizer is rounded to the nearest thousand.
Eylea Vabysmo Eylea HD Avastin Cimerli Lucentis Syfovre Other*
*Other includes: Beovu, Byooviz, Durysta, Iluvien, Izervay, Ozurdex and Yutiq.
2024 biosimilar market share*
Bevacizumab drug group** Figure 141 Avastin
Trastuzumab drug group Figure 142
Hylecta
Rituximab drug group** Figure 143
Rituxan/Rituxan Hycela
Infliximab drug group Figure 144
*Market share is based on unique drug utilizers. Totals may not add up to 100% because drugs with immaterial market share are excluded from the graphics. **Bevacizumab and rituximab market share reflects oncology indication only.
2024 biosimilar market share*
Pegfilgrastim drug group Figure 145
drug group Figure 146
Epoetin alfa drug group Figure 147
Ranibizumab drug group Figure 148
*Market share is based on unique drug utilizers. Totals may not add up to 100% because drugs with immaterial market share are excluded from the graphics.
2024 commercial top 25 drug PMPM spend by site of service Figure 149
2024 Medicaid top 25 drug PMPM spend by site of service Figure 151
2023
CPT code and description
96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug
96365 Intravenous infusion, for therapy, prophylaxis or diagnosis (specify substance or drug); initial, up to 1 hour
96361 Intravenous infusion, hydration; each additional hour
96375 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug
96372 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular Physician
CPT code and description
96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug
67028 Intravitreal injection of a pharmacologic agent (separate procedure)
96365 Intravenous infusion, for therapy, prophylaxis or diagnosis (specify substance or drug); initial, up to 1 hour
20610 Under general introduction or removal procedures on the musculoskeletal system
96372 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
code and
90460 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered
96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug
90480 Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, single dose
96367 Intravenous infusion, for therapy, prophylaxis or diagnosis (specify substance o drug); additional sequential infusion of a new drug/substance, up to 1 hour (list separately in addition to code for primary procedure)
96365 Intravenous infusion, for therapy, prophylaxis or diagnosis (specify substance or drug); initial, up to 1 hour
or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (list separately in addition to code for primary procedure)
infusion, for therapy, prophylaxis or diagnosis (specify substance or drug); each additional hour (list separately in addition to code for primary procedure)
Chemotherapy administration, intravenous infusion technique; each additional hour (list separately in addition to code for primary procedure)
or intramuscular
Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to one hour (list separately in addition to code for primary procedure)
Intravenous infusion, for therapy, prophylaxis or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to one hour (list separately in addition to code for primary procedure)
96416 Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump
administration; intravenous, push technique, each additional substance/drug (list separately in addition to code for
administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, single dose
2024 physician office administration code spend by LOB Figure 154
through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered (list separately in addition to code for primary procedure)
or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (list separately in addition to code for primary procedure)
for
prophylaxis or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to one hour (list separately in addition to code for primary procedure)
Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to one hour (list separately in addition to code for primary procedure)
Immunization administration (includes percutaneous, intradermal, subcutaneous or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (list separately in addition to code for primary procedure)
96415 Chemotherapy administration, intravenous infusion technique; each additional hour (list separately in addition to code for
Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than eight hours), requiring use of a portable or implantable pump
90480 Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, single dose
Methodology
The 2025 edition of the Prime Therapeutics Medical Pharmacy Trend Report was developed utilizing medical pharmacy industry standard methodologies, calculations, guidance from medical drug management experts, and feedback from previous trend reports. Results were based on a noncontinuous population over the five years analyzed. The trend forecast utilized various modeling techniques — including time series modeling, product mapping, custom-component modeling, assumption-based modeling and forecasting by analogy — to generate trends at an LOB level.
This report includes research data obtained through a survey of payers conducted in spring 2025. This information was used to deliver a comprehensive view of payer perceptions and health plan actions related to provider-administered infused or injected drugs paid under the medical benefit, also referred to as medical benefit drugs. These medical benefit drugs are commonly used to treat chronic, progressive, incurable medical disorders.
Health plan claims data
Medical benefit drug utilization and trend data were collected through secondary analyses of commercial, Medicaid and Medicare Advantage health plans’ medical paidclaims data for the most recent calendar years. Claims data was analyzed for medical pharmacy utilization across 1,120 Healthcare Common Procedure Coding System (HCPCS) codes and several outpatient sites of service.*
Analyses compared medical claims data from 2024 to data from 2023. In some cases, the past five years were analyzed to show a longer period of year-over-year spend and trend. All data includes allowed amount costs directly from health plans for medical drugs only. Administration codes were analyzed separately and are discussed in the appendix, pages 61–63
*Diagnostic radiopharmaceuticals were excluded. Drugs administered in the hospital inpatient setting are not included in any analyses. **Not an inclusive list
Drug category
Example drugs**
Cimzia,
Medical benefit drug examples for therapeutic classes Figure 156
CY ......................................................................................................................................................................................................................... calendar year
RA .........................................................................................................................................................................................................rheumatoid arthritis
RARE AI .......................................................................................................................................................... rare autoinflammatory conditions
Reimbursement changes in the level of provider reimbursement, provider mix and site-of-service mix (relative to ASP)
Utilization............................................................................................................................................................................................... number of claims
Utilizers number of unique utilizers
VBC/OBA value based contract/outcomes based agreement
VEGF vascular endothelial growth factor
WAC wholesale acquisition cost
wAMD wet age-related macular degeneration
Biological License Application approvals. U.S. Food and Drug Administration. Published February 7, 2025. Accessed June 23, 2025. https://www.fda.gov/vaccines-blood-biologics/ development-approval-process-cber/2024-biological-license-application-approvals
3 6 Novel drug approvals for 2024. U.S. Food and Drug Administration. Published June 17, 2025. Accessed June 23, 2025. https://www.fda.gov/drugs/novel-drug-approvals-fda/novel-drugapprovals-2024
4 16 NCCN Clinical Practice Guidelines in Oncology: Uterine Neoplasms (Version 3.2025). National Comprehensive Cancer Network. Published 2025. Retrieved from https://www.nccn.org/ guidelines/guidelines-detail?category=1&id=1473
5 21 Wilkins D, Hamrén UW, Chang Y, et al. RSV neutralizing antibodies following nirsevimab and palivizumab dosing. Pediatrics 2024;154(5). doi:10.1542/peds.2024-067174
6 30 Prachar A. New drug, TASCENSO ODT® (Fingolimod), launched. Catalent. Published November 21, 2024. https://www.catalent.com/catalent-news/tascenso-odt-fingolimod/
7 34 NCCN Clinical Practice Guidelines in Oncology: Breast Cancer (Version 4.2025). National Comprehensive Cancer Network. Published 2025. Retrieved from https://www.nccn.org/ guidelines/guidelines-detail?category=1&id=1419
8 35 Medicare Drug Price Negotiation Program: Negotiated prices for initial price applicability year 2026 | CMS. Centers for Medicare & Medicaid Services. Published January 17, 2025. Accessed June 17, 2025. https://www.cms.gov/newsroom/fact-sheets/medicare-drug-price-negotiation-program-negotiated-prices-initial-price-applicability-year-2026
