By Andrew Gottfried, Chief Executive Officer, Nexus Health Group
As the US healthcare landscape continues to evolve, 2025 is set to bring significant transformations driven by shifting policies, regulatory reforms, and rising healthcare costs. Payers must adapt to these changes while ensuring cost-effectiveness and maintaining high standards of care. Pharma and biotech market access teams, in particular, must stay ahead of these trends to navigate the increasingly complex payer environment.
My colleagues at Nexus Health Group, a new integrated and comprehensive market access company offering solutions in strategic consulting, value communications, and patient access and affordability, published a payer perspectives report that identifies crucial industry trends and provides key insights into how payers can stay ahead in an increasingly complex environment. You can read the full report here.
For this trend report, we surveyed payers, including pharmacy and medical directors, across health plans covering 500,000 to more than 5 million lives. From their insights, we identified 6 key trends that will shape market access strategies in 2025:
- Oncology, cell and gene therapies (CGTs), and specialty drug spend remain top payer priorities in 2025. Payers are grappling with rising specialty drug costs, particularly in oncology, CGT, and glucagon-like peptide-1 (GLP-1) management for weight loss. These categories represent the highest-cost areas, necessitating strategic management and budgetary adjustments.
- Payers are seeking better value for healthcare spend. With increasing financial pressures, payers are focusing on optimizing value in healthcare spending. Key concerns include drug utilization, GLP-1 costs, and policy uncertainties surrounding the Inflation Reduction Act (IRA) and pharmacy benefit manager (PBM) regulations.
- Management of key therapeutic areas will be a major focus for payers in 2025. Immunology, oncology, and diabetes are among the top therapeutic areas that payers are actively managing. The rise of innovative treatments, particularly in oncology and CGT, presents both opportunities and challenges in terms of cost and clinical effectiveness.
- Formulary size will remain stable while maximizing savings and rebate revenue. Payers are maintaining formulary sizes while maximizing cost savings. With the rise of biosimilars and Centers for Medicare & Medicaid Services (CMS)-negotiated pricing, payers are balancing cost efficiencies with the need for access to innovative treatments.
- Medical benefit management is on the rise, mirroring pharmacy benefit management. More payers are applying pharmacy benefit management strategies—such as prior authorization and step therapy—to drugs covered under the medical benefit. This shift aims to enhance cost control and ensure the appropriate use of high-cost treatments, particularly in oncology.
- Government and industry uncertainties are what’s keeping payers up at night. Payers are closely watching the impacts of the IRA, PBM reforms, and potential changes in exchange market subsidies. As formularies narrow and utilization management increases, payers are focusing on the comparative value of new drugs entering the market.
2025 will be a year of adaptation and innovation in the payer landscape. To navigate these trends successfully, manufacturers are seeking new approaches to market access, and that’s exactly why Nexus Health Group was created.
Nexus is a new company, but the team is not new to market access. Our decades of experience help us understand that what worked before in market access will not work now or in the future. That is why we have built an approach that uniquely originates at the nexus of value, evidence, and science and meets the needs of stakeholders across the market access spectrum. Learn more about Nexus, meet the team, and read the full Payer Perspectives Report: 2025 Trends and Insights on our website: www.nexushealthgrp.com.
About the Author
Andrew Gottfried, CEO of Nexus Health Group, has been a trusted partner to life-science companies for decades, helping to propel market access into the essential function it is today. He created Nexus Health Group to provide market-leading strategic consulting, value communications, and patient access and affordability solutions that exceed expectations and drive commercial success by eliminating the barriers that may separate patients from their prescribed medications. Connect with Andrew on LinkedIn.
