ST. LOUIS – A larger rebate does not guarantee lower pharmacy spending, warns Paul Pruitt, chief growth officer and co-founder of SHARx, a procurement management solution for high-cost prescription drugs. Demand for GLP-1 medications, specialty drugs and other high-cost therapies is reshaping benefits budgets.
Employers often judge pharmacy performance by discounts, rebates and guarantees, overlooking how utilization, new indications and larger eligible populations affect total spending. "A bigger discount on an escalating drug price can create the illusion of savings," Pruitt warned, noting that as prescription volume grows, employers could be securing better rebates while paying more overall.
"CFOs should focus on the total pharmacy spend," Pruitt urged. "Not the savings percentage printed in the contract."
When Savings Percentages Hide Rising Costs
Consider a hypothetical plan with 100 members using a therapy that costs $10,000 per person annually, equaling $1 million in total. A 10% price reduction combined with growth to 140 users raises spending to $1.26 million, a 26% increase. The lower unit price cannot offset demand. While the surge in popularity of GLP-1s illustrates rapidly expanding utilization, with specialty drugs, what employers see is that even a few claimants can drive disproportionate costs, according to Pruitt. Combining these categories with routine retail claims can mask budget risks.
Forecasting Must Begin Before Renewal
Pruitt recommends modeling GLP-1s, specialty medications, oncology therapies, autoimmune treatments, rare-disease therapies, gene and cell therapies, and high-cost infusions separately. Beyond historical claims, forecasts should track specialty-drug users, new-to-therapy rates, members crossing high-cost claimant thresholds, continuation and persistence rates, pipeline therapies and projected treatment expansion. Regular reviews allow employers to adjust sourcing, member support and budgets before renewal.
Rising use of high-cost therapies and longer-than-expected treatment persistence can signal spending increases. For one employer group with approximately 500 covered lives, SHARx saw utilization trends six months before the fiscal impact appeared in its budget.
"In this case, what appeared to be a stable pharmacy plan became a significant increase in spending," said Pruitt. "This is just one example of utilization trends providing an earlier and more accurate warning signal than discounts or rebate performance alone."
Access Cannot Become the Casualty
Pruitt cautions against blunt restrictions that delay appropriate treatment and generate employee complaints, absenteeism and declining trust in benefits.
"The objective is sustainable access, not indiscriminate approval or denial," Pruitt said.
A responsible strategy combines clinical guidelines, appropriate utilization management, patient advocacy, alternative sourcing and support programs that improve adherence and affordability.
One SHARx member denied coverage for a third-line therapy described the impact: "My health insurance provider refused to cover the third line therapy. Without coverage, this medication would cost me $10,000 every month. SHARx has been a literal lifesaver by providing my medication at no cost to me."
HR and finance leaders must anticipate demand for high-cost therapies, its effect on total spending and the support members need. That makes pharmacy an ongoing risk-management priority.
"A forecast is only valuable if it gives employers a clear line of sight into their expenses and helps them change the outcome," Pruitt said. "The answer cannot be to control spending by simply making medications harder to obtain, because that merely shifts the burden elsewhere and undermines the benefit."
