Issuu

CO M M E R C I A L

MEDICARE

MEDICAID

Medical Pharmacy Trend Report

™

COMPREHENSIVE GUIDE 2026 SIXTEENTH EDITION

Our Medical Pharmacy Trend Report is one of a kind. This industry-leading report is the only detailed source analyzing:

MEDICAL BENEFIT

DATA

MEDICAL BENEFIT

INTEGRATED MEDICAL

CLAIMS TRENDS

BENCHMARKS

DRUG MANAGEMENT

AND PHARMACY DATA

STRATEGIES

Our medical pharmacy experts are dedicated to keeping you informed so you can make better healthcare decisions. Visit our website for webinars, podcasts, past trend reports and more:

CO M M E R C I A L

MEDICARE

MEDICAID

Contributors Laura Walters, RPh

Director, Specialty Clinical Solutions

Ben Messerli, ASA, MAAA Manager, Actuarial Services

Mel Moktan

Actuarial Analyst

Shelae Cheng

Principal, Brand Marketing Strategy

Michelle Booth, PharmD

Sr. Director, Specialty Clinical Solutions

Nicol Brown, PharmD, M.S.

Director, Specialty Clinical Solutions

Samantha Decker, PharmD

Clinical Pharmacist, Specialty Clinical Solutions

Katie Lockhart, M.S.

Contents

Prerak Parikh, PharmD

Executive summary

Medical pharmacy trend drivers

Medical pharmacy trends

Medical benefit categories

Integrated data

Administrative reimbursement codes

Payer survey

Appendix

Methodology

Glossary and references

Abby Kim, PharmD, BCOP

Sr. Director, Oncology Clinical Strategy & Specialty Solutions

Director, Forecasting and Pharmacoeconomics

Director, Specialty Clinical Solutions

Rachael Prusi, PharmD, MSGH Director, Specialty Clinical Solutions

Caroline Quinn, PharmD, BCOP Specialty Clinical Program Director

Kristen Reimers, RPh

Sr. Vice President, Specialty Clinical Solutions

Keya Shah, PharmD

Clinical Pharmacist Project Director

David Eckwright, PharmD, MHI, CSP

Sneha Sharma, PharmD

Dina El Berjawi, PharmD, BCPS

Michael Szatkowski, PharmD, MBA, BCPS

Sr. Director, Specialty Analytics and Informatics

Director, Specialty Clinical Solutions

Natalee Felten, PharmD, BCPS Clinical Pharmacist, Specialty Clinical Solutions

Angela Harris

Sr. Analyst, Forecasting and Pharmacoeconomics

Director, Specialty Clinical Solutions

Devon Trumbower, PharmD, BCPS Director, Specialty Clinical Solutions

Amy Ware, PharmD

Director, Specialty Clinical Solutions

Payer advisory board Mike Ochowski, RPh

Pharmacy Informatics & EMR Support GHC-SCW

John Coleman, PharmD

Sr. Director Clinical Pharmacy Programs Florida Blue

Timothy O’Shea, MS, PharmD Director, Specialty Pharmacy Horizon Blue Cross Blue Shield of New Jersey

Questions? Contact us at MPTrends@PrimeTherapeutics.com. Prime Therapeutics’ 2026 Medical Pharmacy Trend Report is published in partnership with D Custom. All rights reserved. All brand names are the property of their respective owners. The content — including text, graphics, images and information obtained from third parties, licensors and other material (“content”) — is for informational purposes only. The content is not intended to be a substitute for professional medical advice, diagnosis or treatment. Figures may be reprinted with the following citation: Prime Therapeutics Medical Pharmacy Trend Report, Sixteenth Edition © 2026. Used with permission. © 2026 Prime Therapeutics LLC

2026 MEDICAL PHARMACY TREND REPORT

E D I T I O N

5 -Y E A R P M P M T R E N D Figure 1

Executive summary

Commercial

47.2%

$38.66

2021

2022

Medicare

71.0%

Medicaid

44.0%

$48.20

2023

2024

$97.23

$56.90

2025

$106.37

$82.07 $62.21

2021

$67.64

2022

2023

2024

$19.50 $15.32

2021

$44.67

$51.67

$15.31

$16.64

2022

2023

2024

2025

$22.06

2025

TO P D R U G A N D C AT EG O R Y P M P M Figure 2

Commercial Keytruda

Medicare

Medicaid

Oncology

Keytruda

Oncology

Keytruda

Oncology

52.2%

101.9%

92.9%

83.8%

55.7%

2021. . . . . . . . . $2.40

2021. . . . . . . . $14.97

2021. . . . . . . . . $8.07

2021. . . . . . . . $33.05

2021. . . . . . . . . . . $1.11

2021. . . . . . . . . $5.06

2025. . . . . . . . $5.28

2025. . . . . . . $22.78

2025. . . . . . . $16.29

2025. . . . . . . $63.75

2025. . . . . . . . $2.04

2025. . . . . . . . $7.88

120.0%

20 2 5 K E Y T R E N D S Figure 3

20 2 5 T R E N D S* Figure 4 U T I L I Z AT I O N

+10.1% Commercial

Medicare

Medicaid

Enzyme replacement therapies enter top 10

Ophthalmic landscape sees PMPM changes

Gene therapies drive PMPM trend

Increase: Pavblu, Avastin

Increase: Elevidys, Zolgensma

>$1M cost per utilizer for Kanuma and Brineura

Decrease: Eylea, Vabysmo

CO ST

+13.1% +9.4% 9.3%

7.9% 9.8%

3.5% 2.1%

-0.4% Commercial

Medicare

Medicaid

*Due to rounding, totals may not add up accurately.

2026 MEDICAL PHARMACY TREND REPORT

CO M M E R C I A L

MEDICARE

MEDICAID

Medical pharmacy trend drivers Overall landscape The 2025 medical pharmacy data show a market in which spend growth was increasingly concentrated by therapeutic area, but not always by individual product. Across all lines of business (LOBs), the top 20 drug categories captured the vast majority of per member per month (PMPM) spend — ranging from 85.9% for Medicaid to 93.7% for Medicare — while the top 20 drugs captured a smaller share. This divergence suggests that medical pharmacy trend was shaped less by isolated blockbuster products alone and more by clusters of high-cost therapies within oncology, immune-mediated disease, rare

21 Novel medical pharmacy drug approvals in 2025

disease, immune globulin and other specialty categories.

20 2 5 U T I L I Z AT I O N T R E N D BY A N N UA L CO ST* Figure 5 $0–$100

$ 1 0 0 – $ 1 ,0 0 0

$ 1 ,0 0 0 – $ 1 0,0 0 0

$ 1 0,0 0 0 – $ 5 0,0 0 0

Utilization versus cost contributors

$ 5 0,0 0 0 +

Utilization growth was strongest among higher-cost

+1.5%

therapies in 2025, reinforcing the continued shift

+0.9%

of medical pharmacy spend toward more complex

+5.7% +10.5%

specialty categories. Commercial and Medicare each

+10.7%

saw approximately 11% utilization growth in therapies with an annual cost per utilizer of $50,000 or greater,

+1.5%

while Medicaid experienced the sharpest increase in

-2.4%

the $10,000–$50,000 category at 25.7%. Lower-cost

-7.0% +11.1%

categories were relatively flat, particularly therapies

+11.0%

with an annual cost per utilizer of $100–$1,000. Medicare utilization declined in both the $100–$1,000

+3.6%

and $1,000–$10,000 categories as utilization rose in

+0.5% +9.2%

higher-cost categories. Medicaid and commercial +25.7% +15.1%

*Reflects change in utilization of drug and therapy combinations for the various cost/utilizer categories shown.

saw growth across all cost bands, reflecting both increased utilization and a continued shift toward a higher-cost therapy mix.

CO M M E R C I A L

20 2 5 T R E N D FO R TO P 20 D R U G S* Figure 6

PMPM

% change

MEDICARE

MEDICAID

20 2 2 – 20 2 8 P M P M T R E N D S A N D FO R EC AST* * Figure 7

% of total spend 15.5% 8.7%

2022

2025

-0.1%

$24.35 +10.7%

43%

7.9% 21.3%

2023 8.7%

2024

$21.99

7.2% 18.5%

2024

17.2% 10.1%

2025

9.4%

2025

$59.24 +7.4%

13.1%

56% 7.7%

2024

12.0%

2026

$55.16

6.2% 7.6% 10.1%

2027

9.6%

2025

$9.59

6.5%

+23.1%

43%

2028

6.3% 7.6%

2024

$7.79 *Rank based on PMPM spend includes positive or negative changes for 2024-2025. See pages 18-30 for drug- and category-level breakdowns. **Forecasted trends are shown for 2026 forward.

2026 MEDICAL PHARMACY TREND REPORT

CO M M E R C I A L

MEDICARE

MEDICAID

Commercial In 2025, commercial medical pharmacy trend increased by 10.1%, driven primarily by a 7.9%

10.1%

rise in cost and a 2.1% increase in utilization, with double-digit growth in utilizers receiving drugs with annual costs above $10K. Oncology continued to be the primary driver of spend, with stable utilization but a 9% increase in costs driven largely by Keytruda, Darzalex Faspro, Enhertu and Imfinzi. Enzyme replacement therapies entered the top 10 categories by spend with a 23.9% increase driven by high-cost drugs such as Kanuma and Brineura. Other notable trends include the continued decline in the oncology support category with colonystimulating factors, while immune globulin, vaccine and rare disease trended upward.

2025 trend

20 2 5 TO P 5 T H E R A P Y C AT EG O R I ES BY P M P M S P E N D Figure 9 % of spend

$56.90 2025 spend

35% 40%

20 24 – 20 2 5 TO P D R U G T H E R A P Y C AT EG O R I ES BY P M P M S P E N D Figure 8 20 24

20 2 5

$2 2.7 8

$2 0. 93

8.8%

O N CO LO GY B DA I D : C R O H N ’ S D I S E AS E / U LC E R AT I V E CO L I T I S M U LT I P L E S C L E R O S I S

Rare disease

Vaccine

-17.2%

$1 .3 3 $1 .10

0.9%

6.2%

24.7%

Enzyme replacement therapy

$1 .12

R A R E D I S E AS E A L L OT H E R

BDAID: Oncology Ophthalmic rheumatoid support: injections arthritis colony-stimulating factors

$1 .11

$1 .3 0

14%

$1 .14

$1 .4 2 $1 .6 1

$3 .0 3 $3 .5 4 Immune globulin

13.4%

$0 .8 1 $1 .0 1

Multiple sclerosis

I M M U N E G LO BU L I N

16.8%

$0 .9 7 $1 .0 3

Oncology BDAID: Crohn’s disease/ ulcerative colitis

2.2%

$3 .9 3 $4 .0 2

$4 .5 3 $4 .8 1

6.2%

CO M M E R C I A L

MEDICARE

MEDICAID

20 24 – 20 2 5 TO P D R U G S BY P M P M S P E N D W I T H CO M P O N E N TS O F C H A N G E* Figure 10 UTILIZERS

CLAIMS PER UTILIZER

I N F L AT I O N

R E I M BU R S E M E N T

MIX

+$0.48 $0.03

$0.25

+$0.23 +$0.21

$0.10

$0.05 +$0.11

+$0.12 $0.20

+$0.06 $0.04

-$0.07

$0.05

$0.19

$0.08

$0.04

$0.08

$0.05

-$0.03

-$0.04

$0.03

+$0.17

$0.05

$0.04

+$0.20

$0.20 $0.10

$0.23

-$0.04 $0.05

-$0.03

-$0.04

-$0.05 -$0.03

-$0.07

Keytruda

Ocrevus

Entyvio

Opdivo

Darzalex Faspro

Gammagard Liquid

Botox

Perjeta

Enhertu

Prevnar 20

*Values under $0.03 not labeled on graph.

Top 3 drugs driving trend Keytruda was a leading driver of trend, reflecting expanded indications, longer treatment and continued price inflation. Darzalex Faspro grew primarily due to expanded indications within multiple myeloma. Enhertu’s increasing use reflected indication expansion, earlier-line adoption and a broader shift toward high-cost targeted oncology therapies. 2026 MEDICAL PHARMACY TREND REPORT

CO M M E R C I A L

MEDICARE

MEDICAID

20 2 5 P E R- U N I QU E- U T I L I Z E R CO ST L E A D E R S : TO P 1 0 D R U G S Figure 13

20 24 – 20 2 5 TO P 5 D R U G S I N C R E AS I N G TOTA L YOY P M P M S P E N D Figure 11

$3.5M

$0.48

$3.2M

$3.1M

$0.31

$2.8M $0.25

$0.23

$0.21

$1.8M $1.6M Keytruda

Skyrizi

Elevidys

Darzalex Faspro

Enhertu

$1.4M

$1.3M

20 24 – 20 2 5 TO P 5 D R U G S D EC R E AS I N G TOTA L YOY P M P M S P E N D Figure 12 Neulasta

Tepezza

-$0.18

-$0.44

Tysabri

-$0.18

Adcetris

-$0.16

Stelara SQ

-$0.14

Hemgenix

Kanuma

Kalbitor

Elevidys

$0.05

$0.14

$0.04

$0.37

Zolgensma Xenpozyme

$0.05 PMPM

$0.04

Brineura

Lamzede

Amondys 45

Gamifant

$0.03

$0.02

$0.07

$0.05

CO M M E R C I A L

MEDICARE

MEDICAID

20 21 – 20 2 5 P M P M CO ST D I ST R I BU T I O N BY S I T E O F C A R E Figure 14

2021

2021–22 % change

2022

2022–23 % change

2023

2023–24 % change

2024

2024–25 % change

2025

Hospital outpatient (OP)

$19.07

16.5%

$22.22

4.8%

$23.29

7.0%

$24.92

8.9%

$27.13

Physician

$15.21

11.4%

$16.95

10.0%

$18.66

7.6%

$20.07

11.5%

$22.38

Home infusion/ specialty pharmacy (HI/SPP)

$4.37

25.9%

$5.50

13.6%

$6.25

6.9%

$6.68

10.6%

$7.39

Total

$38.66

15.5%

$44.67

7.9%

$48.20

7.2%

$51.67

10.1%

$56.90

20 2 5 U T I L I Z AT I O N T R E N D BY A N N UA L CO ST Figure 15

+11.0%

$0–$99 $100–$999

+9.4%

+10.4%

20 2 5 U T I L I Z AT I O N T R E N D CO M P O N E N TS* Figure 16 UTILIZERS CLAIMS PER UTILIZER

$ 1 ,0 0 0 – $ 9, 9 9 9 $ 1 0,0 0 0 – $ 4 9, 9 9 9 $ 5 0,0 0 0 +

18%

3% 14%

+3.4%

-3%

-1%

+1.2%

$0–$99

$100–$999

-7%

$1,000–$9,999

$10,000–$49,999

$50,000+

*Due to rounding, totals may not accurately match previous graph (utilization trend by annual cost).

2026 MEDICAL PHARMACY TREND REPORT

CO M M E R C I A L

MEDICARE

MEDICAID

Medicare Medicare medical pharmacy trend increased by 9.4% in 2025 driven almost entirely by a

9.4%

9.8% rise in cost. Utilization declined slightly by 0.4% and provided minimal offset. The largest spend increases occurred in oncology, osteoporosis and rare disease. Cost was the primary driver in oncology, and double-digit utilizer growth contributed to trend increases for osteoporosis and rare disease. The ophthalmic injections category retained its position as the second-highest category by spend despite an overall 28.8% PMPM decline. This decline in PMPM spend is due to competition from the introduction of biosimilar Pavblu and increased use of compounded Avastin as lower-cost alternatives. Rare disease spend rose 43.5%, largely due to increased Amvuttra utilization following its expanded ATTR-CM indication.

2025 trend

BY P M P M S P E N D Figure 18 % of spend

$106.37

22%

2025 spend

3% 4%

20 24 – 20 2 5 TO P D R U G T H E R A P Y C AT EG O R I ES BY P M P M S P E N D Figure 17 20 24

20 2 5 TO P 5 T H E R A P Y C AT EG O R I ES

20 2 5

$5 6.1 3

$6 3.7 5

13.6%

60%

O N CO LO GY O P H T H A L M I C I N J EC T I O N S B O N E R ES O R P T I O N I N H I B I TO R S ( O ST EO P O R O S I S )

36.4%

22.8%

-0.6%

-17.2%

$1 .6 5 $2 .2 5

$1 .4 5 $1 .78

$1 .79 $1 .78

$1 .6 9 $1 .6 8

$1 .74 $1 .4 4

Bone resorption inhibitors (osteoporosis)

43.5%

$2 .5 3 $3 .6 3

Ophthalmic injections

I M M U N E G LO BU L I N

16.4%

$3 .5 3 $4 .11

Oncology

33.1%

$3 .3 2 $4 .4 2

$7 .4 8

$1 0. 50

-28.8%

Immune globulin

Rare disease Hematology: myasthenia gravis

Multiple sclerosis

BDAID: Crohn’s BDAID: disease/ rheumatoid ulcerative arthritis colitis

Vaccine

R A R E D I S E AS E A L L OT H E R

CO M M E R C I A L

MEDICARE

MEDICAID

20 24 – 20 2 5 TO P D R U G S BY P M P M S P E N D W I T H CO M P O N E N TS O F C H A N G E* Figure 19 UTILIZERS

CLAIMS PER UTILIZER

I N F L AT I O N

R E I M BU R S E M E N T

MIX

+$1.28

+$0.93

$0.60 +$0.68 +$0.65

$0.44 +$0.35

$0.71 $0.29 -$0.18

$0.59

+$0.53 $1.10 $0.24

$0.27

$0.23

-$2.47 $0.45

+$0.51 -$0.80 $0.22

-$0.36

-$0.30

$0.27 $0.46

+$0.11

-$0.36 -$0.47 -$1.67

-$0.89

-$0.37

Keytruda

Darzalex Faspro

Opdivo

Imfinzi

Xgeva/Prolia

Eylea

Padcev

Vabysmo

Reblozyl

Tecentriq

*Values under $0.11 not labeled on graph.

Top 3 drugs driving trend Eylea experienced market share erosion driven by biosimilar adoption and increased use of alternative therapies. Imfinzi utilization increased following label expansion and adoption of guideline-supported use in earlier lines of therapy. Keytruda’s increase likely reflects a combination of Inflation Reduction Act of 2022-related dynamics, delayed price negotiation and a high inflation baseline. 2026 MEDICAL PHARMACY TREND REPORT

CO M M E R C I A L 20 24 – 20 2 5 TO P 5 D R U G S

MEDICARE

MEDICAID

20 2 5 P E R- U N I QU E- U T I L I Z E R CO ST L E A D E R S : TO P 1 0 D R U G S Figure 22

I N C R E AS I N G TOTA L YOY P M P M S P E N D Figure 20

$1.6M $1.28

$0.93 $0.73

$0.68

$0.65

$0.9M Imfinzi

Keytruda

Amvuttra

Darzalex Faspro

Reblozyl

$0.8M

$0.6M

20 24 – 20 2 5 TO P 5 D R U G S

$0.5M

D EC R E AS I N G TOTA L YOY P M P M S P E N D Figure 21 Eylea

Vabysmo

Cimerli

-$0.31

Tepezza

-$0.23

$0.5M

Trodelvy

-$0.15

-$0.80

-$2.47

Xyntha

Nexviazyme

ACApatch

Carvykti

Givlaari

Soliris

Ilaris

CompleteFT

Tecartus

Hemlibra

$0.19

$0.11

$0.09

$0.33

$0.06

$0.24

$0.06

$0.05

PMPM 12

CO M M E R C I A L

MEDICARE

MEDICAID

20 21 – 20 2 5 P M P M CO ST D I ST R I BU T I O N BY S I T E O F C A R E Figure 23

2021

2021–22 % change

2022

2022–23 % change

2023

2023–24 % change

2024

2024–25 % change

2025

Hospital OP

$29.37

16.3%

$34.16

22.4%

$41.83

32.7%

$55.53

14.7%

$63.70

Physician

$29.95

2.0%

$30.55

22.1%

$37.30

3.7%

$38.69

2.7%

$39.72

HI/SPP

$2.89

1.0%

$2.92

0.7%

$2.94

2.7%

$3.02

-2.3%

$2.95

Total

$62.21

8.7%

$67.64

21.3%

$82.07

18.5%

$97.23

9.4%

$106.37

2025 U T I L I Z AT I O N T R E N D BY A N N UA L CO ST Figure 24 $0–$99

+24.6%

$100–$999

20 2 5 U T I L I Z AT I O N T R E N D CO M P O N E N TS* Figure 25 UTILIZERS CLAIMS PER UTILIZER

$ 1 ,0 0 0 – $ 9, 9 9 9 $ 1 0,0 0 0 – $ 4 9, 9 9 9

+12.8% 47%

$ 5 0,0 0 0 +

+2.3% -8.2%

-0.4%

14% 5%

3% -4%

-13%

$0–$99

$100–$999

-2% -15%

$1,000–$9,999

$10,000–$49,999

$50,000+

*Due to rounding, totals may not accurately match previous graph (utilization trend by annual cost).

CO M M E R C I A L

MEDICARE

MEDICAID

Medicaid In 2025, Medicaid spend increased by 13.1%, driven primarily by a 9.3% rise in cost and

13.1%

a 3.5% increase in utilization. Total PMPM spend rose by $2.56, with rare disease (nonCNS), enzyme replacement therapy and rare disease (CNS) categories contributing

2025 trend

$0.51, or 20%, of the increase. Gene therapies (Zolgensma, Elevidys) along with enzyme replacement therapies (Crysvita, Elaprase) were key drivers of additional spend. Oncology — led by Keytruda, Darzalex Faspro, Blincyto and Enhertu — remained the top spend category, with increasing cost and utilization.

20 2 5 TO P 5 T H E R A P Y C AT EG O R I ES BY P M P M S P E N D Figure 27 % of spend

$22.06 2025 spend

20 24 – 20 2 5 TO P D R U G T H E R A P Y C AT EG O R I ES BY P M P M S P E N D Figure 26 20 24

36%

44%

20 2 5

$7 .8 8

$7 .4 7

5.5% 4%

O N CO LO GY M U LT I P L E S C L E R O S I S R A R E D I S E AS E E N Z Y M E R E P L AC E M E N T

Immune globulin

$0 .5 8 $0 .6 9

17.9%

10.4%

18.6%

56.8%

$0 .3 7 $0 .5 8

Enzyme BDAID: Crohn’s replacement disease/ therapy ulcerative colitis

9.1%

$0 .73 $0 .8 0

$0 .8 1 $0 .9 3

$0 .78 $1 .0 3

$1 .2 0

Rare disease

14.5%

$0 .5 6 $0 .6 6

Multiple sclerosis

31.4%

$0 .6 1 $0 .6 7

Oncology

THERAPY

4.3%

$1 .15

$1 .17 $1 .2 5

6.1%

Contraceptives Antihemophilics

Ophthalmic injections

CNS: rare diseases

B DA I D : C R O H N ’ S D I S E AS E / U LC E R AT I V E CO L I T I S A L L OT H E R

CO M M E R C I A L

MEDICARE

MEDICAID

20 24 – 20 2 5 TO P D R U G S BY P M P M S P E N D W I T H CO M P O N E N TS O F C H A N G E* Figure 28 UTILIZERS

CLAIMS PER UTILIZER

I N F L AT I O N

R E I M BU R S E M E N T

MIX

+$0.22 +$0.14 $0.04

+$0.17

$0.09

+$0.16

$0.04 +$0.09

+$0.09

+$0.08 $0.19

$0.02

+$0.07 $0.03

$0.07

$0.02

$0.10

$0.09

+$0.09

$0.02

$0.05

$0.14 +$0.02

$0.08 $0.06

$0.05

$0.03

$0.04

$0.03 -$0.03

-$0.04 -$0.02

Keytruda

Ocrevus

Opdivo

Darzalex Faspro

Elevidys

Botox

Entyvio

Imfinzi

Zolgensma

Hemlibra

*Values under $0.02 not labeled on graph.

Top 3 drugs driving trend Keytruda and Darzalex Faspro utilization increased, likely driven by expanded indications. Zolgensma utilization rose as diagnoses increased and clinical practice shifted toward treatment immediately following diagnosis. 2026 MEDICAL PHARMACY TREND REPORT 15

CO M M E R C I A L 20 24 – 20 2 5 TO P 5 D R U G S

MEDICARE

MEDICAID

20 2 5 P E R- U N I QU E- U T I L I Z E R CO ST L E A D E R S : TO P 1 0 D R U G S Figure 31

I N C R E AS I N G TOTA L YOY P M P M S P E N D Figure 29

$3.0M $0.22 $0.19 $0.17

Keytruda

Spravato

Darzalex Faspro

$0.16

Zolgensma

Pavblu

$2.5M

$1.4M

$1M

20 24 – 20 2 5 TO P 5 D R U G S D EC R E AS I N G TOTA L YOY P M P M S P E N D Figure 30 Rylaze

Tysabri

-$0.08

Adcetris

-$0.08

Yescarta

-$0.08

$0.9M $0.8M

Tecartus

$0.56

Zolgensma Vyondys 53

$0.6M

$0.31

$0.18

Kymriah

Danyelza

Vyjuvek

Alprolix

Elaprase

Altuviiio

Vimizim

$0.07

$0.05

$0.14

$0.04

$0.22

$0.20

$0.22

PMPM 16

$0.7M

-$0.07

Elevidys

-$0.20

$0.7M

CO M M E R C I A L

MEDICARE

MEDICAID

20 21 – 20 2 5 P M P M CO ST D I ST R I BU T I O N BY S I T E O F C A R E Figure 32

2021

2021–22 % change

2022

2022–23 % change

2023

2023–24 % change

2024

2024–25 % change

2025

Hospital OP

$9.39

-2.2%

$9.18

7.6%

$9.88

25.0%

$12.35

7.3%

$13.25

Physician

$3.91

4.7%

$4.10

16.7%

$4.78

3.7%

$4.96

25.5%

$6.22

HI/SPP

$2.02

0.8%

$2.03

-2.3%

$1.99

10.7%

$2.20

18.0%

$2.59

Total

$15.32

-0.1%

$15.31

8.7%

$16.64

17.2%

$19.50

13.1%

$22.06

2025 U T I L I Z AT I O N T R E N D BY A N N UA L CO ST Figure 33 $0–$99

UTILIZERS

+18.7%

$100–$999

20 2 5 U T I L I Z AT I O N T R E N D CO M P O N E N TS* Figure 34

CLAIMS PER UTILIZER

+15.8%

$ 1 ,0 0 0 – $ 9, 9 9 9 $ 1 0,0 0 0 – $ 4 9, 9 9 9 $ 5 0,0 0 0 +

+8.5% 13%

13% 11%

+3.3%

4% 1% +0.4%

-1%

$0–$99

$100–$999

-2%

$1,000–$9,999

$10,000–$49,999

$50,000+

*Due to rounding, totals may not accurately match previous graph (utilization trend by annual cost).

2026 MEDICAL PHARMACY TREND REPORT 17

CO M M E R C I A L

Oncology* Commercial medical oncology represented 40.0% of PMPM spend, with trend driven by cost (+8.8%)

MEDICARE

MEDICAID

20 21 – 20 2 8 P M P M T R E N D S A N D FO R EC AST* * Figure 35

$33.05

$36.65

$45.14

$56.13 $20.93

$63.75 $22.78

$14.97

$18.00

$19.45

$7.47

$7.88

$5.06

$5.45

$6.04

$81.37

$72.96

$26.48

$24.47

rather than utilization (+0.1%). This suggests greater

$7.99

$88.18 $27.97

$8.72

$9.13

2027

2028

treatment intensity and/or a higher-cost therapy mix. Keytruda remained the leading oncology drug by PMPM ($5.28), supported by its broad clinical footprint and expansion in endometrial

2021

2022

2023

2024

2025

2026

cancer, head and neck cancer, and muscle-invasive bladder cancer. Opdivo remained a significant PMPM driver ($1.63), with recent label expansions in lung and colorectal (COLO) cancers broadening

20 24 – 20 2 5 P M P M T R E N D* * * Figure 36 U T I L I Z AT I O N

its clinical use.

I M PAC T O N T R E N D Figure 38

+13.6%

Medicare showed the strongest oncology cost

+8.9% +16.3%

pressure at three times that of commercial, accounting for 59.9% of medical drug spend. Utilization declined (-2.3%), while cost increased

+0.1%

+5.5% 1.4%

+8.8%

(+16.3%), suggesting that high-cost therapies and

-2.3%

In Medicaid, oncology trend was more balanced Opdivo and Darzalex Faspro were consistent with other lines of business as leading spend drivers. However, Medicaid showed notably higher trend growth for Darzalex Faspro (36.3%).

Keytruda $5.28 PMPM

Opdivo $1.63 PMPM

Darzalex Faspro $1.57 PMPM

10.0%

7.7%

16.7%

Keytruda $16.29 PMPM

Darzalex Faspro $6.84 PMPM

Opdivo $5.37 PMPM

6.0%

11.1%

6.9%

Keytruda $2.04 PMPM

Opdivo $0.66 PMPM

Darzalex Faspro $0.65 PMPM

12.0%

16.1%

36.3%

4.0%

treatment mix more than offset lower use.

across utilization (+4.0%) and cost (+1.4%). Keytruda,

20 2 5 TO P S P E N D D R U G S’

CO ST

20 2 5 % O F M E D I C A L D R U G S P E N D Figure 37

%%%

40.0 59.9 35.7

*Does not include oncology-support drugs such as antiemetics, colony-stimulating factors, gastrointestinal: chemoprotectants and erythropoiesis-stimulating agents. **Forecasted trends are shown for 2026 forward. ***Due to rounding, totals may not add up accurately.

CO M M E R C I A L

Commercial deep dive: Breast cancer Breast cancer remained the highest-spend commercial oncology category in 2025, increasing 8.7% year over year to $5.38 PMPM and

TO P O N CO LO GY S P E N D

B R E AST C A N C E R CO ST P E R

BY C A N C E R T Y P E Figure 39

C L A I M A N D % O F S P E N D* Figure 40

A L L OT H E R B R E AST

M U LT I P L E M Y E LO M A

$1.69 $1.86

increased, while utilization per member remained

$2.04 $12.67

$2.13

received treatment. Average cost per claim

$1.76

Growth was concentrated among a small number

$2.16

of therapies. Keytruda (+$0.17 PMPM) and

$2.24 $8.99

$13.79

$2.25

approximately three-quarters of the category’s

$5.38

total spend increase and expanded their shares

in treated members was the primary trend driver, consistent with expanded treatment eligibility and adoption following Keytruda’s use in high-risk

2025

Keytruda

$19,519

$20,134

23%

25%

Perjeta

$11,899

$12,567

17%

15%

Enhertu

$16,106

$16,596

10%

12%

Kadcyla

$13,912

$13,666

Phesgo

$12,937

$11,892

Trodelvy

$14,972

$15,364

All other

$1,826

$1,903

29%

28%

Total

$4,830

$5,146

100%

2025 20 24 – 20 2 5 B R E AST C A N C E R CO M M E R C I A L CO M P O N E N TS O F C H A N G E* * Figure 41 UTILIZERS

CLAIMS PER UTILIZER

R E I M BU R S E M E N T

I N F L AT I O N

MIX

$0.04 $0.04

early-stage triple-negative breast cancer and Enhertu’s expansion into HER2-low and HER2-

2024

cost therapies.

to 13%, respectively. For both products, growth

2025

$4.95

increased 6.5%, reflecting greater use of higher-

of breast cancer spend from 25% to 27% and 11%

% of spend

2024

U R I N A R Y SYST E M

spend. Claims (+2.1%) and treated members (+2.3%)

Enhertu (+$0.15 PMPM) together accounted for

Cost per claim

G AST R O I N T EST I N A L

R ES P I R ATO R Y

$8.26

MEDICAID

TO P 5 S P E N D

representing approximately 24% of total oncology

stable (-0.2%), indicating that more members

MEDICARE

$0.15

$0.13

ultralow disease.1,2 $0.05 -$0.03

-$0.04

$0.02 $0.02 -$0.02

$0.06

Kadcyla

Phesgo

$0.03 -$0.03 -$0.03

-$0.03 Keytruda

Perjeta

Enhertu

Trodelvy

*Due to rounding, totals may not add up accurately. **See glossary on Page 61 for definition of terms. Values under $0.02 not labeled on graph.

2026 MEDICAL PHARMACY TREND REPORT 19

CO M M E R C I A L

Medicare deep dive: Respiratory oncology Respiratory oncology trend increased materially in 2025, with Medicare PMPM rising 22.9% from $9.91 to $12.18. Cost per claim, not claim volume, was the primary driver of growth: claims per utilizer

TO P O N CO LO GY S P E N D

R ES P I R ATO R Y O N CO LO GY CO ST P E R

BY C A N C E R T Y P E Figure 42

C L A I M A N D % O F S P E N D* Figure 43

A L L OT H E R R ES P I R ATO R Y

U R I N A R Y SYST E M

2025

2024

2025

Keytruda

$12,217

$12,908

48%

43%

Imfinzi

$7,646

$9,471

18%

21%

Tecentriq

$10,805

$11,421

13%

10%

Opdivo

$9,801

$10,218

Rybrevant

$10,969

$12,431

Imdelltra

$15,098

$14,161

$9.08

All other

$1,393

$1,642

12%

$12.18

Total

$5,815

$6,769

100%

B R E AST

$4.66 $5.00 $21.83

$6.96

$34.30

$7.77 $9.91

2024 $5.12

supported by expansion into resectable non-small

$5.68

cell lung cancer (NSCLC) and limited-stage small

$7.90

cell lung cancer (SCLC). Rybrevant also increased

$23.80

$39.95

as EGFR-mutated NSCLC use broadened; its late-2025 subcutaneous formulation may further support uptake by reducing administration time and administration-related reactions versus IV therapy. 3,4 Imdelltra, a first-in-class DLL3-targeted

% of spend

2024

G AST R O I N T EST I N A L

oncology drug in Medicare, but faster-growing Imfinzi was the largest trend contributor (+7.7%),

Cost per claim

M U LT I P L E M Y E LO M A

16.4% and annual cost per utilizer increased 18.7%.

agents exerted greater 2025 trend pressure.

MEDICAID

TO P 5 S P E N D

increased 2.0%, while cost per claim increased

Keytruda remained the highest-spend respiratory

MEDICARE

2025 20 24 – 20 2 5 R ES P I R ATO R Y O N CO LO GY M E D I C A R E CO M P O N E N TS O F C H A N G E* * Figure 44 UTILIZERS

CLAIMS PER UTILIZER

R E I M BU R S E M E N T

I N F L AT I O N

MIX

bispecific T-cell engager for relapsed extensivestage SCLC, added a meaningful option in a $0.44

historically difficult-to-treat setting and signaled growing bispecific use in community oncology. 3,5 $0.20

Together, these shifts suggest respiratory oncology trend is being shaped less by utilization and more

$0.58

$0.12 -$0.12

$0.10

by treatment mix as lower-cost chemotherapy is

-$0.23

-$0.17

Imfinzi

Tecentriq

$0.13

$0.33

Rybrevant

Imdelltra

displaced by higher-cost immunotherapy, targeted therapy and bispecific regimens.

Keytruda

Opdivo

*Due to rounding, totals may not add up accurately. **See glossary on Page 61 for definition of terms. Values under $0.10 not labeled on graph.

CO M M E R C I A L

Medicaid deep dive: Multiple myeloma Multiple myeloma demonstrated one of the highest year-over-year growth rates among top-spend oncology categories in Medicaid, with PMPM

TO P O N CO LO GY S P E N D

M U LT I P L E M Y E LO M A CO ST P E R

BY C A N C E R T Y P E Figure 45

C L A I M A N D % O F S P E N D* Figure 46

A L L OT H E R B R E AST

G AST R O I N T EST I N A L

2024

2025

Darzalex Faspro

$8,610

$9,585

74%

71%

Carvykti

—

$497,957

10%

Kyprolis

$2,188

$2,580

14%

10%

Empliciti

$4,849

$6,083

Sarclisa

$2,578

$5,227

Xgeva/Prolia

$3,285

$3,404

$0.95

All other

$550

$189

$1.07

Total

$3,680

$4,954

100%

$0.70 $3.79

$0.46 $0.88

cost per claim increased 34.6% ($3,680 to $4,954), therapies significantly contributed to spending

2025

$0.70

$3.67

$0.93 2024

growth. Carvykti contributed meaningfully to spend

$0.46

growth, driven by its high cost per claim ($497,957)

$0.62

and expanded patient eligibility.

$0.63 $4.14

$3.73

Darzalex Faspro was the primary driver of category growth, contributing more than half of the total increase in multiple myeloma spend and accounting for 71% of category spend in 2025. Treated members increased 20%, potentially reflecting

% of spend

2024

LEUKEMIA

driven by both utilization and cost trends, as claims

suggesting that greater use of higher-cost

Cost per claim

R ES P I R ATO R Y

M U LT I P L E M Y E LO M A

(+2.2%) and treated members (+9.9%) increased.

MEDICAID

TO P 5 S P E N D

increasing 37.7% from $0.46 to $0.63. Growth was

While claims per utilizer decreased (-7.0%), average

MEDICARE

2025 20 24 – 20 2 5 M U LT I P L E M Y E LO M A M E D I C A I D CO M P O N E N TS O F C H A N G E* * Figure 47 UTILIZERS

CLAIMS PER UTILIZER

R E I M BU R S E M E N T

I N F L AT I O N

MIX

expanded frontline use following a 2024 FDA approval for newly diagnosed multiple myeloma.6 Given its dominant share of category spend, continued adoption across frontline and relapsed

$0.03 $0.01

settings may sustain spending growth.7 $0.07

Darzalex Faspro

$0.06

Carvykti

$0.01 -$0.01 $0.01

$0.01

Kyprolis

Empliciti

Sarclisa

Xgeva/Prolia

*Due to rounding, totals may not add up accurately. **See glossary on Page 61 for definition of terms.

2026 MEDICAL PHARMACY TREND REPORT 21

CO M M E R C I A L

Rare disease*

MEDICAID

20 21 – 20 2 8 P M P M T R E N D S A N D FO R EC AST* * Figure 48

$5.77

$4.24

Rare disease PMPM trend increased across

$2.04

commercial, Medicare and Medicaid in 2025, and it remained among the top five therapy classes by

$1.26

PMPM spend across all LOBs. The annual average

$1.23

cost per utilizer in this category was $490K for

MEDICARE

$1.07

$1.37 $1.33

$1.54

$2.53 $1.73

$1.18

$1.22

$5.00

$3.67

$1.82

$1.52

$1.78

2024

2025

$1.99

$2.20 $2.08

2027

2028

$2.04

$1.97 $1.89

commercial, $166K for Medicare and $526K for Medicaid. Forecasts project continued growth over

2021

2022

2023

2026

the next three years at a rate of 14% in commercial, 57% in Medicare and 24% in Medicaid, reflecting ongoing unmet need and a robust rare disease pipeline.

20 24 – 20 2 5 P M P M T R E N D* * * Figure 49 U T I L I Z AT I O N

+45.0%

Commercial spend increased 5.0%, driven by higher cost despite decreased utilization. Tepezza remained the top contributor to commercial spend,

+56.5%

although PMPM decreased from 2024 to 2025. Elevidys and Amvuttra were notable commercial

+17.1%

+7.3%

Duchenne muscular dystrophy indication and

-2.1%

+22.1% -7.3%

accounted for more than half of Medicare rare disease PMPM, and Amvuttra accounted for nearly one-third. For Medicaid, Elevidys, Zolgensma and Spinraza accounted for 64% of total rare disease PMPM.

Elevidys $0.37 PMPM

Amvuttra $0.17 PMPM

-26.7%

212.2%

151.7%

Reblozyl $2.10 PMPM

Amvuttra $1.16 PMPM

Tepezza $0.31 PMPM

45.2%

172.3%

-42.1%

Elevidys $0.56 PMPM

Zolgensma $0.31 PMPM

Spinraza $0.27 PMPM

33.3%

107.4%

22.1%

-4.1%

Amvuttra’s approval for transthyretin amyloid by 45.0%, driven by higher utilization. Reblozyl

Tepezza $0.50 PMPM

+5.0%

trend drivers, likely reflecting Elevidys’ expanded

cardiomyopathy. Medicare PMPM increased

20 2 5 TO P S P E N D D R U G S’ I M PAC T O N T R E N D Figure 51

CO ST

20 2 5 % O F M E D I C A L D R U G S P E N D Figure 50

%%% 3.2

3.5

8.1

*Rare disease in this section includes combined data from CNS: rare disease and rare disease (non-CNS) therapy categories. **Forecasted trends are shown for 2026 forward. ***Due to rounding, totals may not add up accurately.

CO M M E R C I A L

Hematology

MEDICARE

20 21 – 20 2 8 P M P M T R E N D S A N D FO R EC AST* * Figure 52

$5.54

$4.97

double-digit trend growth from 2024 to 2025.

$3.09 $1.73 $0.96

$1.38

19.0%, from $1.60 to $1.89, driven more by utilization gravis (MG) increased from $0.09 to $0.29 PMPM,

$2.92

$2.19 $1.15

For the commercial LOB, PMPM spend increased than cost. Vyvgart Hytrulo spend for myasthenia

$4.31

$3.81

The hematology category accounted for less than 4% of overall medical drug spend but experienced

MEDICAID

$0.64

$0.71

$0.66

2021

2022

2023

$2.13

$2.38

$2.60

$1.60

$1.89

$0.48

$0.64

$0.71

$0.81

$0.89

2024

2025

2026

2027

2028

likely supported by the 2025 introduction of a prefilled syringe formulation and a rise in unique utilizers from 0.5 to 1.1 per 100,000 members.

20 24 – 20 2 5 P M P M T R E N D* * * Figure 53 U T I L I Z AT I O N

Medicare PMPM spend increased 30.3%, from

+32.5%

$2.92 to $3.81, with utilization contributing more to trend than cost. Ultomiris had PMPM and utilizer

+18.7%

increases across MG, neuromyelitis optica spectrum

+ 0.3%

+30.3% + 9.9%

disorder, aHUS and PNH. For Medicaid, PMPM spend increased 32.5%, from $0.48 to $0.64. The increase in trend was primarily attributable to

+18.4%

+18.6%

Vyvgart Hytrulo $0.29 PMPM

Nplate $0.26 PMPM

13.5%

234.6%

4.3%

Ultomiris $1.28 PMPM

Vyvgart $1.00 PMPM

Nplate $0.44 PMPM

68.6%

11.0%

10.1%

Ultomiris $0.22 PMPM

Nplate $0.11 PMPM

Soliris $0.08 PMPM

27.0%

-13.1%

-20.9%

-4.7%

utilization declined, a 27.0% increase in Ultomiris utilization, driving a 39.0% increase in costs.

Ultomiris $0.65 PMPM

+39.1%

conversion from Soliris to Ultomiris. Although overall utilization outweighed a 21.0% decrease in Soliris

20 2 5 TO P S P E N D D R U G S’ I M PAC T O N T R E N D Figure 55

CO ST

20 2 5 % O F M E D I C A L D R U G S P E N D Figure 54

%%% 3.3

3.6

2.9

*Hematology drugs included in this report are Adakveo, Nplate, Panhematin, rituximabs, Rystiggo, Soliris, Ultomiris, Uplizna and Vyvgart/Vyvgart Hytrulo. Rituximab products were only included when used for hematologic indications. **Forecasted trends are shown for 2026 and forward. ***Due to rounding, totals may not add up accurately.

2026 MEDICAL PHARMACY TREND REPORT 23

CO M M E R C I A L

BDAIDs

MEDICARE

MEDICAID

20 21 – 20 2 8 P M P M T R E N D S A N D FO R EC AST* * Figure 56

* $5.90

$6.45

$6.58

$8.85

$8.38

$7.60

$7.97

$4.20

$4.04

$6.91

In 2025, biologic drugs for autoimmune disorders (BDAIDs) accounted for 13.4% of commercial spend, led by Crohn’s disease and ulcerative colitis.

$3.37

$4.11

$4.15 $2.87

$3.00

$3.06

$1.52

$1.39

$1.57

$1.66

$1.81

$1.89

2021

2022

2023

2024

2025

2026

Commercial BDAID trend rose 10.1%, primarily from higher utilization. Entyvio remained the top-utilized agent but posted its first negative trend (-3.2%), potentially reflecting a shift to the

$2.04

$2.20

2027

2028

subcutaneous formulation under the pharmacy benefit. Biosimilar adoption continued to reduce Remicade spend, which has declined by about half over five years. Overall trend remained positive due to increased use of branded agents including Skyrizi and Tremfya.

20 24 – 20 2 5 P M P M T R E N D* * * Figure 57 U T I L I Z AT I O N

+10.1%

+9.2%

+ 2.4%

+2.3%

In Medicare, PMPM trend increased 2.2% in 2025 and is projected to decline over the next three years. Entyvio remained the highest PMPM spend

+ 2.2% +7.5%

+0.4%

+1.8%

Medicaid, trend increased 9.2%, driven largely by higher Skyrizi and Orencia utilization. Unlike in commercial and Medicare, Entyvio posted a positive trend in Medicaid (5.0%), suggesting slower movement to the subcutaneous formulation. Medicaid also saw negative trends for Remicade and Actemra.

Entyvio $2.13 PMPM

Remicade $1.03 PMPM

Skyrizi $0.74 PMPM

-3.2%

-9.3%

74.0%

Entyvio $1.14 PMPM

Orencia $0.60 PMPM

Remicade $0.45 PMPM

-8.8%

1.3%

-9.6%

Entyvio $0.44 PMPM

Skyrizi $0.18 PMPM

Inflectra $0.18 PMPM

5.0%

116.8%

-1.0%

+6.7%

contributor despite a hefty trend decrease of -8.8%, followed by Orencia and Remicade. For

20 2 5 TO P S P E N D D R U G S’ I M PAC T O N T R E N D Figure 59

CO ST

20 2 5 % O F M E D I C A L D R U G S P E N D Figure 58

%%% 13.4

4.0

8.2

*Autoimmune disorders in this section include ankylosing spondylitis, Crohn’s disease/ulcerative colitis (UC), psoriasis/psoriatic arthritis (PS/PSA), rare autoinflammatory conditions (RAI), rheumatoid arthritis (RA) and systemic lupus erythematosus. **Forecasted trends are shown for 2026 forward. ***Due to rounding, totals may not add up accurately.

CO M M E R C I A L

MEDICARE

MEDICAID

B DA I D T H E R A P Y C H A N G E B R E A K D OW N Figure 60 I N C R E AS E

$6.91

2024 PMPM

$4.11

2024 PMPM

$1.66

2024 PMPM

D EC R E AS E

TOTA L

$0.18

$0.13

$0.08

$0.04

$0.02

$7.60

Crohn’s/ UC

Other

Lupus

RAI

PS/PSA

2025 PMPM

$0.08

$0.01

$0.00

$0.23

Other

RAI

Lupus

PS/PSA

$0.12

$0.04

$0.01

$0.00

Crohn’s/ UC

Other

Lupus

$4.20 -$0.01

-$0.01

Crohn’s/ UC

2025 PMPM

$1.83 -$0.01

-$0.02

PS/PSA

RAI

2025 PMPM

2026 MEDICAL PHARMACY TREND REPORT 25

CO M M E R C I A L

Multiple sclerosis Commercial MS therapy PMPM continued to

20 21 – 20 2 8 P M P M T R E N D S A N D FO R EC AST* Figure 61

$3.62

$3.82

$3.93

$1.49

$1.38

Briumvi, which launched for MS in 2023, continued to gain market share. Its increasing utilization may be driven by provider preference, shorter infusion time (one hour versus two hours for Ocrevus),

$4.02

$4.65

$4.36

MEDICAID

$4.95

$3.16

increase in 2025, with growth expected to continue into the forecast period primarily driven by cost.

MEDICARE

$1.78

$1.91

$1.55

$1.45

$1.17

$1.23

$1.32

$1.41

2024

2025

2026

2027

$0.88

$0.92

$1.01

2021

2022

2023

$2.04

$1.50

2028

lower wholesale acquisition cost, and the fact that postinfusion monitoring is at physician discretion after the first two infusions, while observation continues throughout Ocrevus treatment.

20 24 – 20 2 5 P M P M T R E N D* * Figure 62 U T I L I Z AT I O N

+0.9%

Medicare experienced similar continued growth in MS therapy spend, driven primarily by increased

+2.2%

utilization. This trend may reflect a growing number of patients with MS who are living longer and aging

+23.1%

+4.9% Ocrevus $3.06 PMPM

Tysabri $0.55 PMPM

Briumvi $0.34 PMPM

+22.1%

1.9%

-25.0%

118.9%

-14.1%

Ocrevus $1.36 PMPM

Tysabri $0.30 PMPM

Briumvi $0.09 PMPM

17.9%

27.3%

92.6%

Ocrevus $0.98 PMPM

Briumvi $0.13 PMPM

Tysabri $0.11 PMPM

9.7%

109.7%

-46.1%

+22.1%

+12.5%

into Medicare or potential growth in late-onset MS. Medicaid PMPM was largely cost driven. Briumvi

20 2 5 TO P S P E N D D R U G S’ I M PAC T O N T R E N D Figure 64

CO ST

-9.1%

overtook Tysabri as the No. 2 spend driver, with PMPM increasing 109.7% year over year.

20 2 5 % O F M E D I C A L D R U G S P E N D Figure 63

%%% 7.1

1.7

5.6

*Forecasted trends are shown for 2026 forward. **Due to rounding, totals may not add up accurately.

CO M M E R C I A L

Vaccines

$1.68

(+20.9%) were the leading contributors, reflecting a

$0.09 $0.08 $0.08

$0.22 $0.10

$1.96

$1.91

$1.74

$2.07

$1.44

$0.54

commercial population, driven primarily by higher stable (+0.5%). Prevnar 20 (+33.7%) and Beyfortus

MEDICAID

20 21 – 20 2 8 P M P M T R E N D S A N D FO R EC AST* Figure 65

From 2024 to 2025, vaccine spend rose 13.8% in the cost (+13.3%), as utilization remained relatively

MEDICARE

$0.64

$1.14 $1.30

$0.26 $0.44

$0.47

2024

2025

$1.52

$1.37

$1.67

$0.54

$0.59

$0.64

2026

2027

2028

continued shift toward higher-cost immunizations. The Prevnar 20 trend was also supported by the

2021

2022

2023

Advisory Committee on Immunization Practices’ October 2024 recommendation to expand routine pneumococcal vaccination from adults age 65 and older to all adults age 50 and older.

20 24 – 20 2 5 P M P M T R E N D* * Figure 66 U T I L I Z AT I O N

+13.8%

A different pattern emerged in Medicare, where vaccine spend declined 17.6%, as a 25.5% reduction

+0.5% +13.3%

in utilization more than offset a 10.7% growth in

-17.6%

+6.9%

+10.7%

+8.3%

cost. Lower spend for Spikevax (-28.4%) and -25.5%

decrease, consistent with continued normalization of COVID-19 vaccine demand following the peak pandemic period.

primary driver of vaccine trend, with PMPM spend increasing 6.9% despite a modest decline in utilization (-1.3%). Prevnar 20 (+29.6%) led growth in the category, while a lower COVID-19 vaccine spend partially offset the overall PMPM trend.

Prevnar 20 $0.81 PMPM

MenQuadfi $0.13 PMPM

Beyfortus $0.13 PMPM

33.7%

6.4%

20.9%

Prevnar 20 $0.81 PMPM

Spikevax Monovalent $0.32 PMPM

Comirnaty Monovalent $0.29 PMPM

-6.0%

-28.4%

-24.3%

Prevnar 20 $0.27 PMPM

Comirnaty Monovalent $0.08 PMPM

Spikevax Monovalent $0.05 PMPM

29.6%

-9.7%

-17.7%

-1.3%

Comirnaty (-24.3%) contributed to the overall

For Medicaid, higher unit cost remained the

20 2 5 TO P S P E N D D R U G S’ I M PAC T O N T R E N D Figure 68

CO ST

20 2 5 % O F M E D I C A L D R U G S P E N D Figure 67

%%% 2.3

1.4

2.1

*Forecasted trends are shown for 2026 forward. **Due to rounding, totals may not add up accurately.

2026 MEDICAL PHARMACY TREND REPORT 27

Biosimilar trends

RANIBIZUMAB MEDICARE

P EG F I LG R AST I M CO M M E R C I A L

M A R K E T S H A R E Figure 69

M A R K E T S H A R E Figure 70

LU C E N T I S

BYO OV I Z

CIMERLI

Across all LOBs, biosimilar market shares increased slightly for most categories, yet biosimilar cost

40%

claim increased 41% from the previous year.

Ranibizumab

ST I M U F E N D

FYLNETRA

14% 4%

64% 100%

NYVEPRIA

15%

notable in commercial, where biosimilar cost per

FULPHILA

Z I E XT E N ZO

26%

per claim increased at a faster rate. This was most

N E U L ASTA

4% 22%

14%

30% 22% 29%

100%

72%

Cimerli began the year with more than half of the

35%

72%

4% 57%

60%

market share across all LOBs, but it ended 2025

55%

32%

43%

with no market share after production was paused. Nearly all Cimerli share shifted back to Lucentis.

Tocilizumab Tyenne experienced rapid uptake across all LOBs, increasing from 5% market share in the first quarter of 2025 to 45% in the fourth quarter of 2025 in

2021

2022

2023

2024

2025

2021

2023

T R AST U Z U M A B CO M M E R C I A L M A R K E T S H A R E Figure 72

R I T UX A N

R I T UX A N H YC E L A

HERCEPTIN

R UX I E N C E

T R UX I M A

HERZUMA

RIABNI

20% 46%

49%

42%

50%

31%

33%

28%

11% 27%

by year-end.

40%

25%

2% 10%

2021

2022

38%

31%

52%

54% 2% 2%

1% 16%

17%

2023

2024

47%

9% 2025

15%

10%

2021

2022

19%

32% 1% 2%

31%

36%

41%

2025 with no market share and reached 20% in

OGIVRI

TRAZIMERA

the first biosimilar market entry. Pavblu started commercial, 24% in Medicare and 52% in Medicaid

2025

H E R C E P T I N H Y L EC TA KANJINTI

ONTRUZANT

24%

2024

M A R K E T S H A R E Figure 71

Aflibercept Eylea market share began to erode following

2022

R I T UX I M A B M E D I C A I D

commercial.

2% 2% 7%

1% 4%

14% 6%

U D E N YCA

8% 2023

30% 1% 2%

6% 2024

29% 3%

6% 2025

CO M M E R C I A L

MEDICARE

MEDICAID

Biosimilar market share* B E VAC I Z U M A B D R U G G R O U P * *

P EG F I LG R AST I M D R U G G R O U P

R I T UX I M A B D R U G G R O U P * *

T R AST U Z U M A B D R U G G R O U P

Figure 73

Figure 74

Figure 75

Figure 76

AVAST I N

N E U L ASTA

R I T UX A N / R I T UX A N H YC E L A

H E R C E P T I N / H E R C E P T I N H Y L EC TA

M VAS I

FULPHILA

R UX I E N C E

KANJINTI

ZIRABEV

U D E N YC A

T R UX I M A

OGIVRI

A LY M SYS

NYVEPRIA

RIABNI

ONTRUZANT

V EG Z E L M A

ST I M U F E N D

TRAZIMERA

FYLNETRA

2% 4%

2% 2%

24%

31%

28%

29%

40%

30%

48%

62% 35%

17%

27%

28%

12%

37%

13% 31%

50%

42%

26%

1% 5% 11%

22%

42%

24%

7% 1%

10%

35%

15%

27%

31%

37%

30%

46%

53% 52%

40%

13%

*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 indications only.

2026 MEDICAL PHARMACY TREND REPORT 29

CO M M E R C I A L

Ophthalmic injections

MEDICARE

MEDICAID

20 21 – 20 2 8 P M P M T R E N D S A N D FO R EC AST* Figure 77

$10.50 $9.06 $6.67

$9.27

$9.51

$9.74

$7.48

$7.18

Ophthalmic injections remained a key driver of medical spend in 2025, with utilization shifting

$0.73

$0.78

toward newer anti-VEGF therapies. Commercial

$0.19

$0.21

2021

2022

$0.97

$1.03

$1.10

$1.19

$1.28

$0.35

$0.56

$0.66

$0.80

$0.90

$0.97

2023

2024

2025

2026

2027

2028

$0.87

PMPM increased 6.6% to $1.03, driven primarily by higher utilization of Vabysmo and Eylea HD. Medicare PMPM declined as lower-cost alternatives and market share shifts offset utilization growth.

20 24 – 20 2 5 P M P M T R E N D* * Figure 78 U T I L I Z AT I O N

I M PAC T O N T R E N D Figure 80

+18.6%

Product mix continued to evolve across the category. Following their recent launches, Eylea HD +6.6%

adoption accelerated and Vabysmo experienced strong utilization growth and gained market share.

+2.3%

+4.2%

-28.8%

+15.6%

+0.2%

+2.7%

Traditional Eylea utilization declined as patients transitioned to newer therapies. Biosimilar uptake

-28.9%

remained modest but continued to provide downward pressure on costs. In Medicare, compounded bevacizumab remained an important low-cost treatment option and continued to support affordability within the category. Despite declines in some legacy products, ophthalmic injections remain a significant contributor to medical drug spend due to ongoing growth in anti-VEGF treatment volume and

Eylea $0.43 PMPM

Vabysmo $0.26 PMPM

Eylea HD $0.15 PMPM

-16.2%

27.9%

81.5%

Eylea $2.57 PMPM

Vabysmo $2.19 PMPM

Eylea HD $0.59 PMPM

-49.0%

-26.9%

11.8%

Eylea $0.26 PMPM

Pavblu $0.16 PMPM

Vabysmo $0.15 PMPM

-15.3%

New in ’25

49.0%

20 2 5 % O F M E D I C A L D R U G S P E N D Figure 79

%%% 1.8

7.0

3.0

adoption of newer agents. *Forecasted trends are shown for 2026 forward. **Due to rounding, totals may not add up accurately.

20 2 5 TO P S P E N D D R U G S’

CO ST

Integrated data

At a glance

For the second consecutive year, this report

20 2 5 M E M B E R S H I P :

16.9M 1.0M

includes a cross-benefit analysis of members with claims data across both medical and pharmacy benefits. This integrated view of specialty drug

Commercial

trends shows that the top 12.6% of commercial members accounted for 92% of total cost in 2025.

MEDICARE IMMUNE G LO BU L I N :

though commercial plan members generally have

Panzyga

more options for where they receive specialty drug

24%

administration. By examining claims data from both 2024 and 2025, this analysis offers a more holistic perspective on utilization, cost drivers and site-of-

spend shift to RX

care dynamics.

A N N UA L S P E N D D I ST R I BU T I O N O F CO M M E R C I A L P O P U L AT I O N Figure 81 % MEMBERS

% CO ST

15.4%

Keytruda remains the top spend oncology drug.

Commercial

However, its Medicare

Medicare

contribution was reduced

41.2%

by 0.5% YOY.

CO M M E R C I A L S H A R E O F TOTA L

M E D I C A R E S H A R E O F TOTA L

CO ST BY S I T E O F C A R E Figure 82

CO ST BY S I T E O F C A R E Figure 83

FAC I L I T Y

72.8%

Double-digit growth

Medicare

Notably, total cost by site of care is nearly the same for commercial and Medicare populations, even

MS SPEND TREND:

P H A R M ACY

FAC I L I T Y

HOME P R O F ES S I O N A L

HOME

P H A R M ACY

P R O F ES S I O N A L

58.2%

9.6% 12.8%

14.6% 8.0% 0.0% $0

$0K–$2.5K

18.2%

12.1%

$2.5K–$100K

15.6%

0.4%

0.1%

$100K–$250K

>$250K

75.6%

2.1%

0.3% 9.5% 10.9%

79.3%

2026 MEDICAL PHARMACY TREND REPORT 31

CO M M E R C I A L

MEDICARE

MEDICAID

Drug name

2024

2025

Avonex

$8,191

$8,537

Briumvi

$31,968

$36,679

glatiramer

$1,765

$1,788

Kesimpta

$8,933

$9,569

Mavenclad

$72,792

$79,109

increased 18% from 2024 to 2025 across the

Ocrevus

$41,840

$43,942

pharmacy and medical benefits, with spend

Rebif

$10,514

$10,928

Tysabri

$8,971

$9,114

Vumerity

$8,567

$8,938

Zeposia

$8,784

$9,149

CO ST P E R C L A I M * Figure 85

S P E N D BY B E N E F I T T Y P E

Integrated multiple sclerosis

Figure 84 % MEDICAL % P H A R M ACY

Commercial The total PMPM for the multiple sclerosis category

47.7%

52.3%

distributed approximately evenly between the two. The cost per claim increased for each of the top 10 drugs used across both benefits. Ocrevus and Kesimpta continued to account for the highest PMPM spend in the category, while Briumvi

TO P 1 0 D R U G S BY CO M B I N E D M E D I C A L A N D P H A R M ACY P M P M S P E N D* * Figure 86

PMPM more than doubled from $0.15 in 2024 to

20 24 M E D I C A L

$0.34 in 2025. Unlike Medicare, where utilization

20 24 P H A R M ACY

20 2 5 M E D I C A L

20 2 5 P H A R M ACY

patterns differ, Ocrevus utilization remained $0.01

almost exclusively on the medical benefit for the commercial population.

$2.00

$2.30

$2.51

$1.00

$1.43 $0.99 $0.60 $0.61

2024 total 2025 total

$0.29 $0.37

$0.28

$0.15

$0.34

$0.23 $0.26

$0.18 $0.17

$0.19 $0.16

$0.10 $0.09

Ocrevus

Kesimpta

Tysabri

Zeposia

Vumerity

Briumvi

Mavenclad

Avonex

Rebif

glatiramer

$2.31 $2.51

$0.99 $1.43

$0.61 $0.61

$0.29 $0.37

$0.28 $0.36

$0.15 $0.34

$0.23 $0.26

$0.18 $0.17

$0.19 $0.16

$0.10 $0.09

*Data presented in descending order of highest PMPM spend. **Due to rounding, totals may not add up accurately.

$0.36

CO M M E R C I A L

Figure 87 % MEDICAL

Avonex and Kesimpta had the largest increases

% P H A R M ACY

in PMPM spend on the pharmacy benefit from 2024 to 2025. Increased utilization of Kesimpta, Avonex, Vumerity and Mavenclad likely contributed to corresponding PMPM increases for these

33.7%

therapies. Ocrevus remained the highest-spend 66.3%

multiple sclerosis therapy despite a slight decrease in PMPM on the medical benefit. Additionally, a greater proportion of Ocrevus utilization was covered under Medicare Part D in 2025 compared with 2024 (16.5% versus 9.7%), with the IV formulation accounting for the majority of Part D claims. The increased utilization observed under

Drug name

2024

2025

Avonex

$8,091

$8,934

Briumvi

$22,456

$27,905

Copaxone

$6,228

$5,976

glatiramer

$1,879

$1,828

Kesimpta

$9,356

$9,624

Mavenclad

$78,733

$79,384

Ocrevus

$31,970

$33,534

Rebif

$11,116

$12,238

Tysabri

$7,324

$7,339

Vumerity

$8,819

$9,277

TO P 1 0 D R U G S BY CO M B I N E D M E D I C A L A N D P H A R M ACY P M P M S P E N D* * Figure 89

the pharmacy benefit likely reflects a growing

20 24 M E D I C A L

number of Ocrevus home infusion claims. Briumvi also had notable PMPM growth, driven by higher utilization and increased claim volume.

MEDICAID

CO ST P E R C L A I M * Figure 88

S P E N D BY B E N E F I T T Y P E

Medicare

MEDICARE

$0.14

20 24 P H A R M ACY

20 2 5 M E D I C A L

20 2 5 P H A R M ACY

$0.24

$1.20

$0.80 $1.28 $1.21

$0.06 $0.95

$0.40

$0.02 $0.63

$0.45

2024 total 2025 total

$0.57

$0.54

$0.22

$0.27

Vumerity Mavenclad

Ocrevus

Kesimpta

Avonex

$1.42 $1.45

$0.45 $0.95

$0.22 $0.63

$0.27 $0.57

$0.46 $0.23 $0.23

$0.12 $0.16

$0.17 $0.15

$0.05 $0.01 $0.01 $0.13

Tysabri

Copaxone

Rebif

glatiramer

Briumvi

$0.41 $0.52

$0.23 $0.23

$0.12 $0.16

$0.17 $0.15

$0.06 $0.14

$0.38

$0.17

$0.17 $0.54

*Data presented in alphabetical order by drug name. **Due to rounding, totals may not add up accurately.

2026 MEDICAL PHARMACY TREND REPORT 33

CO M M E R C I A L

MEDICARE

MEDICAID

Drug name

2024

2025

% P H A R M ACY

Asceniv

$48,751

$55,693

5.9%

Cuvitru

$2,220

$2,101

Gammagard

$4,866

$5,121

Gammaplex

$5,817

$5,115

Gamunex

$4,202

$4,269

Hizentra

$2,294

$2,112

HyQvia

$4,768

$5,088

the medical benefit, which accounted for 94% of the

Octagam

$4,921

$4,536

total immune globulin spend. Gammagard remained

Panzyga

$6,194

$6,211

the top-spend drug across benefits, with 2025

Privigen

$4,664

$4,641

CO ST P E R C L A I M * Figure 91

S P E N D BY B E N E F I T T Y P E

Integrated immune globulin

Figure 90 % MEDICAL

Commercial Combined medical and pharmacy immune globulin spend continued to increase for the commercial LOB, with the average cost per claim increasing 7%

94.1%

year over year. Spend remained predominantly on

PMPM increasing by $0.14 compared with 2024. TO P 1 0 D R U G S BY CO M B I N E D M E D I C A L A N D P H A R M ACY P M P M S P E N D* * Figure 92

Medical benefit immune globulin (IG) spend was

20 24 M E D I C A L

20 24 P H A R M ACY

20 2 5 M E D I C A L

20 2 5 P H A R M ACY

$0.03

also influenced by several higher-cost products, including Panzyga, Gammaplex and Asceniv. Products used across both the medical and

$1.20

pharmacy benefits — including Hizentra, Cuvitru and HyQvia — continued to contribute to spend across channels. Cuvitru PMPM more than

$0.02

$0.80

$0.01 $1.40

doubled, increasing from $0.14 to $0.34, while HyQvia increased from $0.09 to $0.16. Hizentra

$0.88

$0.40

$0.01

$0.74

remained a meaningful cross-benefit contributor at

$0.39

$0.36 PMPM.

Reported off-label utilization in claims and related

$0.34

$0.37

Gammagard Gamunex

$0.11

$0.24 $0.25

$0.02 $0.29

2024 total 2025 total

$0.76 $0.90

$0.47 $1.43

$0.17

$0.26 $0.13

$0.04 $0.06 $0.03 $0.17 $0.12

$0.07 $0.09

Privigen

Octagam

Hizentra

Cuvitru

Panzyga Gammaplex HyQvia

Asceniv

$0.39 $0.61

$0.34 $0.37

$0.35 $0.36

$0.14 $0.34

$0.17 $0.26

$0.07 $0.09

literature further supports continued management opportunities in this category.

$0.11

$0.12

Commercial IG utilization increased 16.2%, suggesting broader use across indications.

$0.04

$0.61 $0.46

*Data presented in alphabetical order by drug name. **Due to rounding, totals may not add up accurately.

$0.13 $0.17

$0.09 $0.16

CO M M E R C I A L

Figure 93 % MEDICAL

Integrated Medicare immune globulin data trends

% P H A R M ACY

differed from commercial, with the majority of spend billed through the pharmacy benefit. IG utilization under the pharmacy benefit is primarily driven by Medicare Part D coverage for primary immunodeficiency. Pharmacy benefit claims

45.8% 54.2%

accounted for 54.2% of the total IG spend compared

MEDICAID

Drug name

2024

2025

Cuvitru

$1,808

$1,893

Gammagard

$4,288

$4,383

Gammaplex

$11,441

$13,217

Gamunex

$4,406

$4,354

Hizentra

$2,261

$2,320

HyQvia

$5,199

$6,070

Octagam

$3,386

$3,269

Panzyga

$8,674

$15,134

Privigen

$3,175

$2,909

Xembify

$3,137

$2,958

CO ST P E R C L A I M * Figure 94

S P E N D BY B E N E F I T T Y P E

Medicare

MEDICARE

with 45.8% on the medical benefit. Gammagard and Gamunex were the top contributors to the IG PMPM spend across benefits. Most IG products included in the Medicare analysis demonstrated PMPM growth in 2025,

TO P 1 0 D R U G S BY CO M B I N E D M E D I C A L A N D P H A R M ACY P M P M S P E N D* * Figure 95

indicating increased utilization across the category.

20 24 M E D I C A L

Gammagard and Gamunex were key drivers of the total spend, with Gamunex increasing 11.7% year

20 24 P H A R M ACY

20 2 5 M E D I C A L

20 2 5 P H A R M ACY

$2.40

over year. Gammaplex also contributed to PMPM growth, increasing 25.2% to $1.29 PMPM, while Privigen remained a steady $0.95.

$1.42

$1.80

$1.30

$0.03

Given the influence of Part B reimbursement

$1.20

$1.04 $0.02

dynamics on Medicare IG spend, continued average sales price (ASP) monitoring remains an

$0.88

$0.60

$1.26

$1.26 $1.29

important component of management strategy for

$0.25 $0.21

$1.00 $0.70 $0.73

$0.66 $0.68

$0.35 $0.39

this category. Gammagard Gamunex Gammaplex Privigen 2024 total 2025 total

$2.56 $2.70

$1.54 $1.72

$0.13 $0.14

$1.03 $1.29

$0.95 $0.95

$0.09 $0.12 $0.23

$0.03 $0.24 $0.05

$0.09 $0.10 $0.06 $0.04 $0.04 $0.03 $0.03 $0.04 $0.02 $0.05$0.06 $0.02 $0.03 $0.15

Octagam

Hizentra

Panzyga

Cuvitru

Xembify

HyQvia

$0.48 $0.53

$0.32 $0.36

$0.09 $0.17

$0.12 $0.14

$0.08 $0.11

$0.06 $0.09

*Data presented in alphabetical order by drug name. **Due to rounding, totals may not add up accurately.

2026 MEDICAL PHARMACY TREND REPORT 35

CO M M E R C I A L

Figure 96 % MEDICAL % P H A R M ACY

Commercial The commercial oncology spend continued to be

38.6%

distributed across both the medical and pharmacy

61.4%

benefits, with the majority of expenditures occurring under the medical benefit. In 2025, 61.4% of the total oncology spend was attributed to the medical benefit while 38.6% was attributed to the pharmacy benefit. Analysis of the top oncology therapies by allowed PMPM indicates

Across the top 10 therapies, total allowed PMPM

Drug name

2024

2025

Darzalex

$14,270

$16,545

Enhertu

$12,261

$13,576

Imfinzi

$14,360

$17,005

Keytruda

$19,858

$22,432

Kisqali

$15,270

$15,248

Mvasi

$4,126

$4,267

Opdivo

$14,249

$15,835

Perjeta

$11,589

$13,980

Revlimid

$17,339

$18,170

Verzenio

$12,506

$13,345

TO P 1 0 D R U G S BY CO M B I N E D M E D I C A L A N D P H A R M ACY P M P M S P E N D* * Figure 98

that spending remained concentrated among a relatively small number of high-cost therapies.

MEDICAID

CO ST P E R C L A I M * Figure 97

S P E N D BY B E N E F I T T Y P E

Integrated oncology

MEDICARE

20 24 M E D I C A L

20 24 P H A R M ACY

20 2 5 M E D I C A L

20 2 5 P H A R M ACY

$6.00

increased by approximately 21% from 2024 to 2025. Keytruda remained the greatest contributor to

$4.00

oncology spend during both years. Other therapies $4.88

demonstrating notable growth in allowed PMPM included Kisqali and Darzalex, while Revlimid was

$5.89

$2.00

the only therapy among the top 10 to experience a decline, likely driven by generic adoption of

$1.42

$1.85

$1.57

$1.84 $1.32 $1.38

The cost per claim increased across most of the leading oncology therapies. The average cost per claim for the top 10 therapies analyzed increased by approximately 11% between 2024 and 2025.

$1.21 $0.61

lenalidomide.

2024 total 2025 total

$0.71

$0.97

$0.80 $0.86

$0.74

$0.83

$0.54 $0.74

$0.83 $0.66

Keytruda

Darzalex

Opdivo

Verzenio

Kisqali

Enhertu

Perjeta

Mvasi

Imfinzi

Revlimid

$4.88 $5.89

$1.42 $1.85

$1.57 $1.84

$1.32 $1.38

$0.61 $1.21

$0.71 $0.97

$0.80 $0.86

$0.74 $0.83

$0.54 $0.74

$0.83 $0.66

*Data presented in alphabetical order by drug name. **Due to rounding, totals may not add up accurately.

CO M M E R C I A L

MEDICARE

MEDICAID

Drug name

2024

2025

Brukinsa

$13,182

$13,286

Calquence

$13,430

$13,360

Darzalex

$8,606

$9,330

Ibrance

$14,868

$15,389

Imfinzi

$8,189

$9,581

Keytruda

$12,369

$12,783

lenalidomide

$11,332

$11,175

Opdivo

$9,201

$9,676

decline in PMPM. Among the drugs evaluated,

Revlimid

$16,702

$17,786

Xtandi, lenalidomide and Brukinsa experienced

Xtandi

$12,880

$13,152

CO ST P E R C L A I M * Figure 100

S P E N D BY B E N E F I T T Y P E

Medicare

Figure 99 % MEDICAL

The Medicare oncology spend was distributed

% P H A R M ACY

relatively evenly between the medical and pharmacy benefits, with 50.5% of spend attributed to the medical benefit and 49.5% to the pharmacy benefit. 49.5%

Across the top 10 therapies analyzed, combined

50.5%

allowed PMPM increased approximately 9% from 2024 to 2025. Keytruda remained the largest contributor to oncology spend despite a modest

the most notable PMPM growth, while Revlimid TO P 1 0 D R U G S BY CO M B I N E D M E D I C A L A N D P H A R M ACY P M P M S P E N D* * Figure 101

experienced the largest decline, likely driven

20 24 M E D I C A L

by generic adoption and the resulting shift in utilization from branded Revlimid to generic lenalidomide.

$0.04

20 24 P H A R M ACY

20 2 5 M E D I C A L

20 2 5 P H A R M ACY

$0.06

$2.40

The cost per claim remained relatively stable overall compared with the commercial population,

$1.80 $15.43

increasing approximately 3% across the top 10 drugs. The largest year-over-year increases in cost per claim were observed for Imfinzi (+17%), Darzalex

$0.03 $0.04

$16.02 $0.05 $0.07

$1.20 $7.54

(+8%) and Opdivo (+5%).

$3.90

2024 total 2025 total

$0.01

$6.38

$7.15

$5.34

$4.97

$7.45

$5.11

$2.91

$3.92 $2.62

$2.55

$3.40

$3.33

$2.24

$3.30

$2.45

$3.21

Keytruda

Darzalex

Xtandi lenalidomide Opdivo

Brukinsa

Imfinzi

Revlimid

Ibrance

Calquence

$16.06 $15.49

$7.17 $7.57

$3.90 $6.38

$2.62 $3.92

$2.55 $3.41

$7.45 $3.33

$2.24 $3.30

$2.45 $3.21

$2.91 $5.34

$5.02 $5.18

*Data presented in alphabetical order by drug name. **Due to rounding, totals may not add up accurately.

2026 MEDICAL PHARMACY TREND REPORT 37

CO M M E R C I A L

MEDICARE

MEDICAID

Administrative reimbursement codes 20 2 5 TO P A D M I N I ST R AT I V E CO D ES BY P M P M FO R H O S P I TA L O U T PAT I E N T A N D P H YS I C I A N O F F I C E* Figure 102

CPT code and description**

2024

2025

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; each additional sequential IV push of a new drug/substance 90460 Vaccine administration through age 18 with counseling by physician/ qualified healthcare professional; first or only vaccine/ toxoid component administered

Physician

Hospital

Total PMPM

CPT code and description**

$0.33

$1.00

$1.33

$0.35 $1.26

$1.61

96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug

$0.14

$0.66

$0.52

$0.15 $0.59 $0.74 $0.01

$0.46

$0.47

$0.01 $0.52 $0.53 $0.05

$0.39 $0.44

$0.05 $0.43 $0.49 $0.39 $0.00 $0.39 $0.40 $0.00 $0.40

67028 Intravitreal injection of a pharmacologic agent (separate procedure)

Hospital

Total PMPM

$0.27

$1.41

$1.68

$0.25 $1.31

$1.56

$0.14

$0.94

$0.80

$0.77 $0.16 $0.93

20610 Major joint/ bursa arthrocentesis, aspiration and/or injection; without ultrasound guidance

$0.44 $0.24

96365 Intravenous infusion, for therapy, prophylaxis or diagnosis (specify substance or drug); initial, up to 1 hour

$0.10

96374 Therapeutic, prophylactic or diagnostic injection; initial or single IV push of a drug/substance

*Due to rounding, totals may not add up accurately. **Some of the descriptions have been shortened for this publication. Please refer to CMS for full HCPCS codes.

Physician

$0.67

$0.41 $0.27 $0.68 $0.57

$0.67

$0.09 $0.52 $0.62 $0.01

$0.46

$0.47

$0.01 $0.52 $0.53

CPT code and description** 90460 Vaccine administration through age 18 with counseling by physician/qualified healthcare professional; first or only vaccine/ toxoid component administered 96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug

96367 IV infusion; additional sequential infusion of a new drug/ substance, up to 1 hour (separate from primary procedure)

90480 COVID-19 vaccine administration by intramuscular injection; single dose

96365 Intravenous infusion, for therapy, prophylaxis or diagnosis (specify substance or drug); initial, up to 1 hour

Physician

Hospital

Total PMPM

$0.25

$0.03

$0.28

$0.24 $0.03 $0.27 $0.01

$0.08 $0.09

$0.01 $0.06 $0.07 $0.01

$0.04 $0.05

$0.00 $0.04 $0.05 $0.05

$0.02

$0.06

$0.03 $0.01 $0.04 $0.01

$0.03

$0.01 $0.03 $0.03

Payer survey

57 payers

246

million covered lives

O U R E X P E RTS Figure 103

Pharmacy directors, VPs, chief pharmacy officers Medical directors, VPs, clinical managers

68% 32%

In the 2026 edition of the payer survey, we present insights from

G EO G R A P H I C D I S P E R S I O N O F L I V ES Figure 104

executives from 57 health plans

Number of plans with lives in each region

P L A N S I Z E Figure 105

47 million lives

covering 246 million lives. All U.S. regions are represented, with many plans operating across regions. Regional plans (23) make up the

largest group, followed by national

27 M I DW EST

W EST

plans (20), which is a useful lens for interpreting management

Median: 2 million lives

NORTHEAST

sophistication and operational

constraints. State/local health plans

SOUTH

(14) made up the remainder of the

2,700 lives

plans responding to the survey. Where applicable throughout the report, we will call out major differences in responses based on plan type. Read the complete payer

L I V ES B R E A K D OW N BY L I N E O F BU S I N ES S

L I V ES B R E A K D OW N BY P L A N T Y P E Figure 107

Figure 106

survey report for even more valuable

19%

insights on industry topics.

MEDICARE

60%

N AT I O N A L , N = 20 P L A N S

196.3 million lives R EG I O N A L , N = 2 3 P L A N S

CO M M E R C I A L

21%

MEDICAID

42.2 million lives STAT E / LO C A L , N = 1 4 P L A N S

7.5 million lives

2026 MEDICAL PHARMACY TREND REPORT 39

Hot topics Our latest survey dives into the hottest trends shaping the

Artificial intelligence (AI) A I U S E BY P L A N T Y P E Figure 108

H OW A I I S U T I L I Z E D Figure 109

% of payers (N=57)

# of payers (N=40, multiple answers allowed)

N AT I O N A L

R EG I O N A L

STAT E / LO C A L

future of managed care. From the transformative role of AI in pharmacy — where plans are exploring innovative ways to harness its potential while maintaining

Administrative tasks (taking notes, scheduling

61%

Chatbot agents

21% 79%

Research (online or within internal systems)

Predictive analytics and/or forecasting

Y ES

25% 75% 39%

clinical precision and regulatory compliance — to the ripple effects of the 2026 expiration of Affordable Care Act subsidies, we uncover how these changes are impacting

plan enrollments and reshaping the healthcare landscape. We also

meetings, drafting emails and documents)

Fraud, waste and abuse detection and monitoring

explored regulatory readiness, focusing on how prepared plans are for the Centers for Medicare

I M P L E M E N T I N G O R P I LOT I N G A I - E N A B L E D P R I O R

& Medicaid Services’ transition to

AU T H O R I Z AT I O N FO R M E D I C A L B E N E F I T D R U G S Figure 110

reimbursement influenced by the maximum fair price (MFP) — a shift expected to be a significant strategic consideration in the years ahead. In addition, we asked respondents to identify the single biggest challenge or concern their organization faces related to physician‑administered medical benefit drugs.

% of payers (N=40)

70% of plans are using AI tools as part of daily work.

Y ES, F U L LY IMPLEMENTED

6% 48%

CO N S I D E R I N G

28%

P I LOT I N G O R I N D E V E LO P M E N T

18% NO

CURRENT PLANS

Membership and regulatory TO P B E N E F I T M A N AG E M E N T CO N C E R N S

P L A N P R E PA R E D N ES S FO R C M S’ T R A N S I T I O N TO M F P - I N F LU E N C E D

A N D C H A L L E N G ES Figure 113

R E I M BU R S E M E N T FO R PA RT B D R U G S Figure 111 % of payers (N=51, Medicare plans only)

Site of care Patient outcomes

59%

F U L LY P R E PA R E D M O D E R AT E LY P R E PA R E D

Prior authorization

M I N I M A L LY P R E PA R E D N OT P R E PA R E D/ U N S U R E

16% 7%

18%

Financial risk

Costs

Payment delays

Formulary preferred drugs

P L A N E N R O L L M E N T C H A N G ES F R O M 20 2 5 TO 20 26 Figure 112

Increase

57%

No change

Decrease

23%

20%

39%

18%

36%

24%

Medicare

40%

Provider contracted rates Fee schedules White-bagging

M E M B E R S H I P S H I F TS I N E XC H A N G E P L A N S Figure 114

Commercial

43%

Data monitoring Hospital markup

25%

Equal percentages of plans saw an increase or decrease in membership.

Medicaid 2026 MEDICAL PHARMACY TREND REPORT 41

Oncology General oncology management strategies An emerging trend in oncology is the approval of subcutaneous

TO P CO N C E R N S W I T H S Q FO R M U L AT I O N S Figure 115 % of payers (N=57) CO ST

PAT I E N T SAT I S FAC T I O N

CO M PA R AT I V E E F F I C ACY

UNSURE

TO I V FO R M

D E L AY E D B I O S I M I L A R

R EG I M E N CO N TA I N S S Q

CO N V E R S I O N

A N D I V P R O D U C TS

(SQ) forms of medications that were previously only available as

intravenous (IV) formulations (e.g., Opdivo Qvantig and Keytruda Qlex).

56%

The vast majority of plans (89%) have implemented coverage strategies for these new formulations. Shifts in utilization from IV to SQ formulations are occurring at the same rate

regardless whether it is a new start or continuation of therapy, or if the SQ medication is a part of a singledrug or multidrug regimen. Most

53%

of these SQ formulations are still provider-administered and require the same monitoring for toxicities as the IV formulations. Plans are overwhelmingly interested (93%) in monitoring oncology treatment via reports that span across pharmacy and medical benefits.

20%

of plans are seeing a shift to SQ formulations of oncology drugs.

63% of plans have implemented or are implementing regimen-based reviews; 18% of plans do not have but would prefer this type of review. 44% of plans manage radiopharmaceuticals for both diagnostic and treatment purposes; 35% manage for treatment only.

R A D I O P H A R M AC E U T I C A L M A N AG E M E N T ST R AT EG I ES Figure 117 # of payers (N=49, multiple answers allowed)

Prior authorization

Postservice claim edits/dose optimization

Fee schedule

TO P C H A L L E N G E TO P E R FO R M I N G O N CO LO GY R EG I M E N - BAS E D P R I O R AU T H O R I Z AT I O N R E V I E WS Figure 116 % of payers (N=46)

Medical and pharmacy benefits managed by different groups

Provider communication/ access to chart notes

No current

26% 22%

challenges

Solution not offered by current vendor/benefit manager

Unsure

39%

For even more valuable insights on industry topics and emerging payer strategies, read the complete payer survey report.

9% 4% 2026 MEDICAL PHARMACY TREND REPORT 43

CO M M E R C I A L

MEDICARE

MEDICAID

Appendix 20 2 2 – 20 2 5 M E D I C A L P H A R M ACY P M P M A L LOW E D A M O U N T AT S I T E O F C A R E LO B B R E A KO U T Figure 118

2022

2022–23 % change

2023

2023–24 % change

2024

2024–25 % change

2025

Home

$5.50

13.8%

$6.25

6.9%

$6.68

10.5%

$7.39

Hospital OP

$22.22

4.8%

$23.29

7.0%

$24.92

8.9%

$27.13

Physician

$16.95

10.0%

$18.66

7.6%

$20.07

11.5%

$22.38

Total

$44.67

7.9%

$48.20

7.2%

$51.67

10.1%

$56.90

Home

$2.92

0.5%

$2.94

2.6%

$3.02

-2.0%

$2.95

Hospital OP

$34.16

22.4%

$41.83

32.7%

$55.53

14.7%

$63.70

Physician

$30.55

22.1%

$37.30

3.7%

$38.69

2.7%

$39.72

Total

$67.64

21.3%

$82.07

18.5%

$97.23

9.4%

$106.37

Home

$2.03

-2.3%

$1.99

10.7%

$2.20

18.0%

$2.59

Hospital OP

$9.18

7.6%

$9.88

25.0%

$12.35

7.3%

$13.25

Physician

$4.10

16.7%

$4.78

3.7%

$4.96

25.5%

$6.22

Total

$15.31

8.7%

$16.64

17.2%

$19.50

13.1%

$22.06

Commercial

Medicare

Medicaid

CO M M E R C I A L

MEDICARE

MEDICAID

20 2 5 TO P 20 CO M M E R C I A L P M P M S P E N D BY T H E R A P Y C AT EG O R Y Figure 119

Rank

Therapy

2024 PMPM

2025 PMPM

2024–2025 % change

2025 % of total PMPM

Cost per claim

Utilizers per 100K mbrs

Claims per utilizer

2025 ASP index*

Oncology

$20.93

$22.78

8.9%

40.0%

$5,140

936.3

5.7

1.8

BDAID: Crohn’s disease/ulcerative colitis

$4.53

$4.81

6.3%

8.5%

$6,517

168.5

5.3

1.6

Multiple sclerosis

$3.93

$4.02

2.2%

7.1%

$30,662

58.7

2.7

1.6

Immune globulin

$3.03

$3.54

16.9%

6.2%

$3,988

65.6

16.2

1.5

Rare disease

$1.42

$1.61

13.5%

2.8%

$59,079

3.9

8.3

2.0

Vaccine

$1.14

$1.30

13.8%

2.3%

$270

4,908.7

1.2

1.6

BDAID: rheumatoid arthritis

$1.11

$1.12

1.4%

2.0%

$3,193

72.7

5.8

1.3

Oncology support: colony-stimulating factors

$1.33

$1.10

-17.2%

1.9%

$3,343

96.0

4.1

2.3

Ophthalmic injections

$0.97

$1.03

6.6%

1.8%

$1,279

236.6

4.1

1.2

Enzyme replacement therapy

$0.81

$1.01

23.9%

1.8%

$24,701

2.3

21.0

1.6

Botulinum toxins

$0.81

$0.99

22.4%

1.7%

$1,414

303.2

2.8

1.4

Respiratory

$0.86

$0.98

14.6%

1.7%

$1,376

501.6

1.7

1.2

Hematology: MG

$0.61

$0.87

42.6%

1.5%

$22,270

3.6

13.1

1.2

Antihemophilics

$0.81

$0.87

7.0%

1.5%

$17,832

4.9

12.0

1.3

HIV

$0.51

$0.78

53.4%

1.4%

$6,447

35.9

4.0

1.1

Bone resorption inhibitors (osteoporosis)

$0.47

$0.61

30.0%

1.1%

$2,176

195.4

1.7

1.3

BDAID: systemic lupus erythematosus

$0.45

$0.58

30.1%

1.0%

$4,965

16.6

8.5

1.2

Iron, intravenous

$0.53

$0.54

1.7%

1.0%

$476

483.9

2.8

1.9

BDAID: psoriasis/psoriatic arthritis

$0.37

$0.41

10.8%

0.7%

$3,685

25.6

5.2

1.3

BDAID: other

$0.23

$0.41

78.3%

0.7%

$5,251

21.6

4.3

1.6

*ASP index compares the unit cost on the claim to the ASP unit cost reported by CMS.

2026 MEDICAL PHARMACY TREND REPORT 45

CO M M E R C I A L

MEDICARE

MEDICAID

20 2 5 TO P 20 M E D I C A R E P M P M S P E N D BY T H E R A P Y C AT EG O R Y Figure 120

Rank

Therapy

2024 PMPM

2025 PMPM

2024–2025 % change

2025 % of total PMPM

Cost per claim

Utilizers per 100K mbrs

Claims per utilizer

2025 ASP index*

Oncology

$56.13

$63.75

13.6%

59.9%

$4,269

3,187.8

5.6

1.11

Ophthalmic injections

$10.50

$7.48

-28.8%

7.0%

$772

2,568.3

4.5

1.08

Bone resorption inhibitors (osteoporosis)

$3.32

$4.42

33.2%

4.2%

$1,642

1,970.4

1.6

1.10

Immune globulin

$3.53

$4.11

16.7%

3.9%

$2,569

148.0

13.0

1.09

Rare disease

$2.53

$3.63

43.6%

3.4%

$19,231

26.1

8.7

1.07

Hematology: MG

$1.65

$2.25

36.2%

2.1%

$16,485

11.9

13.8

1.06

Multiple sclerosis

$1.45

$1.78

23.1%

1.7%

$19,592

41.7

2.6

1.07

BDAID: Crohn’s disease/ulcerative colitis

$1.79

$1.78

-0.6%

1.7%

$4,657

89.5

5.1

1.12

BDAID: rheumatoid arthritis

$1.69

$1.68

-0.6%

1.6%

$2,306

145.3

6.0

1.09

Vaccine

$1.74

$1.44

-17.6%

1.4%

$209

7,866.2

1.0

0.99

Oncology support: colony-stimulating factors

$1.33

$1.25

-5.7%

1.2%

$917

309.0

5.3

1.09

Botulinum toxins

$0.98

$1.08

10.4%

1.0%

$945

508.7

2.7

1.07

Viscosupplementation

$0.93

$0.95

2.3%

0.9%

$309

1,663.2

2.2

1.07

Gout

$0.87

$0.84

-3.5%

0.8%

$28,418

3.1

11.4

1.05

Iron, intravenous

$0.60

$0.63

5.1%

0.6%

$397

746.8

2.5

1.09

Oncology support: other

$0.60

$0.56

-6.6%

0.5%

$4,785

24.7

5.7

1.08

Respiratory

$0.60

$0.55

-8.3%

0.5%

$618

677.6

1.6

1.08

Hematology

$0.44

$0.52

18.0%

0.5%

$2,935

11.7

18.2

1.07

Hematology: NMOSD

$0.39

$0.50

29.6%

0.5%

$63,394

3.2

2.9

1.07

Cardiovascular agent

$0.37

$0.48

28.3%

0.5%

$124

3,138.4

1.5

1.12

*ASP index compares the unit cost on the claim to the ASP unit cost reported by CMS.

CO M M E R C I A L

MEDICARE

MEDICAID

20 2 5 TO P 20 M E D I C A I D P M P M S P E N D BY T H E R A P Y C AT EG O R Y Figure 121

Rank

Therapy

2024 PMPM

2025 PMPM

2024–2025 % change

2025 % of total PMPM

Cost per claim

Utilizers per 100K mbrs

Claims per utilizer

2025 ASP index*

Oncology

$7.47

$7.88

5.5%

35.7%

$3,336

572.7

4.9

1.07

Multiple sclerosis

$1.17

$1.25

6.1%

5.6%

$21,520

32.7

2.1

1.08

Rare disease

$1.15

$1.20

4.3%

5.4%

$54,082

2.6

10.1

2.69

Enzyme replacement therapy

$0.78

$1.03

31.4%

4.7%

$14,429

3.4

25.3

1.08

BDAID: Crohn’s disease/ulcerative colitis

$0.81

$0.93

14.5%

4.2%

$4,020

65.3

4.3

1.22

Immune globulin

$0.73

$0.80

9.1%

3.6%

$2,254

34.9

12.2

1.05

Antihemophilics

$0.61

$0.67

10.4%

3.1%

$16,376

5.0

9.8

1.03

Ophthalmic injections

$0.56

$0.66

18.6%

3.0%

$1,094

212.0

3.4

1.14

Botulinum toxins

$0.48

$0.55

14.8%

2.5%

$1,253

225.8

2.3

1.08

Vaccine

$0.44

$0.47

6.9%

2.1%

$201

2,579.9

1.1

1.36

BDAID: rheumatoid arthritis

$0.38

$0.39

1.9%

1.8%

$2,569

35.8

5.1

1.11

HIV

$0.14

$0.31

113.5%

1.4%

$6,579

16.7

3.4

1.12

Substance use disorder agents

$0.16

$0.28

70.8%

1.3%

$1,259

100.4

2.7

1.01

Oncology support: colony-stimulating factors

$0.27

$0.26

-2.4%

1.2%

$1,479

57.1

3.7

1.16

Bone resorption inhibitors (osteoporosis)

$0.18

$0.24

35.4%

1.1%

$1,606

109.8

1.6

1.09

Respiratory

$0.21

$0.23

12.8%

1.1%

$381

531.2

1.4

1.05

Iron, intravenous

$0.17

$0.22

28.1%

1.0%

$214

512.0

2.4

1.13

Wound care

$0.09

$0.21

123.3%

0.9%

$9,160

9.3

2.9

1.11

Hematology: MG

$0.02

$0.20

708.9%

0.9%

$16,299

1.7

9.0

1.01

BDAID: systemic lupus erythematosus

$0.16

$0.19

23.5%

0.9%

$3,690

8.7

7.1

1.04

*ASP index compares the unit cost on the claim to the ASP unit cost reported by CMS.

2026 MEDICAL PHARMACY TREND REPORT 47

CO M M E R C I A L

MEDICARE

MEDICAID

20 2 5 CO M M E R C I A L TO P 2 5 D R U G P M P M S P E N D BY S I T E O F C A R E Figure 122

Therapy

Brand

Oncology

PMPM

Cost per claim

Utilization trend (2024–2025)

Hospital OP

Physician

Home

Hospital OP

Physician

Home

Hospital OP

Physician

Home

Keytruda

$3.64

$1.63

$0.00

$25,891

$15,042

$11,948

57%

Oncology

Opdivo

$1.12

$0.52

$0.00

$18,918

$11,191

$14,552

—

Oncology

Darzalex Faspro

$1.06

$0.51

$0.00

$18,697

$11,561

$9,708

13%

10%

125%

Oncology

Perjeta

$0.63

$0.23

$0.00

$14,611

$8,919

$7,751

-6%

-14%

—

Oncology

Enhertu

$0.58

$0.28

$0.00

$19,943

$13,012

$12,222

29%

23%

-49%

Oncology

Imfinzi

$0.49

$0.24

$0.00

$21,483

$12,159

$13,928

15%

18%

—

Oncology

Mvasi

$0.50

$0.10

$0.00

$5,770

$2,336

$2,961

15%

27%

738%

Oncology

Yervoy

$0.34

$0.18

$0.00

$38,057

$27,282

$14,048

16%

15%

—

Oncology

Kadcyla

$0.34

$0.14

$0.00

$15,056

$10,954

20%

-7%

—

BDAID: Crohn’s disease/UC

Entyvio

$0.47

$1.10

$0.56

$12,990

$7,870

$8,768

-9%

-2%

BDAID: Crohn’s disease/UC

Remicade

$0.28

$0.30

$0.17

$5,858

$2,146

$2,729

-8%

-1%

BDAID: Crohn’s disease/UC

Skyrizi

$0.28

$0.33

$0.13

$24,706

$12,842

$13,945

36%

59%

44%

Botulinum toxins

Botox

$0.17

$0.71

$0.05

$2,332

$1,328

$1,143

12%

17%

15%

Contraceptives

Mirena

$0.04

$0.35

$0.01

$2,067

$1,336

$1,210

19%

14%

13%

HIV

Cabenuva

$0.07

$0.47

$0.07

$12,108

$6,868

$7,009

26%

47%

32%

Immune globulin

Gammagard Liquid

$0.33

$0.31

$5,863

$4,269

$4,597

12%

20%

14%

Immune globulin

Gamunex-C/ Gammaked

$0.23

$0.15

$0.29

$4,495

$5,149

$4,178

36%

26%

12%

Immune globulin

Privigen

$0.23

$0.11

$0.22

$7,723

$3,348

$5,062

27%

31%

22%

Immune globulin

Octagam

$0.03

$0.18

$0.22

$13,084

$3,532

$5,132

18%

22%

Multiple sclerosis

Ocrevus

$1.40

$1.27

$0.39

$63,522

$39,889

$37,064

-3%

16%

Multiple sclerosis

Tysabri

$0.22

$0.27

$0.06

$14,953

$8,078

$8,247

-33%

-22%

-8%

Ophthalmic injections

Eylea

$0.03

$0.40

$0.00

$4,302

$2,067

$1,929

-15%

-54%

Rare disease

Tepezza

$0.05

$0.32

$0.13

$74,903

$61,177

$58,504

-54%

-8%

-34%

Respiratory

Xolair

$0.06

$0.46

$0.05

$4,517

$2,622

$2,886

-2%

16%

-13%

Vaccine

Prevnar 20

$0.02

$0.78

$0.01

$450

$314

$292

22%

28%

26%

Due to rounding, totals may not add up accurately. Entries represented by “ —” indicate no spend, whereas entries represented by “$0.00” indicate spend less than $0.01.

CO M M E R C I A L

MEDICARE

MEDICAID

20 2 5 M E D I C A R E TO P 2 5 D R U G P M P M S P E N D BY S I T E O F C A R E Figure 123

Therapy

Brand

Oncology

PMPM

Cost per claim

Utilization trend (2024–2025)

Hospital OP

Physician

Home

Hospital OP

Physician

Home

Hospital OP

Physician

Home

Keytruda

$12.09

$4.21

$0.00

$13,300

$12,680

—

-6%

—

Oncology

Darzalex Faspro

$4.67

$2.17

$0.00

$9,855

$9,616

—

11%

—

Oncology

Opdivo

$4.08

$1.29

$0.00

$10,959

$10,073

—

-5%

—

Oncology

Imfinzi

$2.74

$1.14

$0.00

$10,098

$11,173

—

19%

34%

—

Oncology

Padcev

$1.66

$0.59

$0.00

$9,082

$8,154

—

24%

—

Oncology

Tecentriq

$1.47

$0.54

$0.00

$11,419

$11,118

—

-2%

—

Oncology

Enhertu

$1.02

$0.41

$0.00

$10,137

$9,755

—

52%

—

Oncology

Pluvicto

$1.12

$0.17

$0.00

$44,610

$40,297

—

-20%

86%

—

Oncology

Yervoy

$0.88

$0.38

$0.00

$18,518

$20,061

—

16%

-13%

—

Oncology

Xgeva/Prolia

$0.73

$0.46

$0.00

$3,208

$3,233

—

-4%

-12%

—

Oncology

Kyprolis

$0.53

$0.49

$0.00

$3,046

$3,500

—

-3%

39%

—

Oncology

Opdualag

$0.72

$0.30

$0.00

$32,942

$31,810

—

-3%

132%

—

Oncology

Perjeta

$0.69

$0.18

$0.00

$7,520

$7,441

—

11%

-18%

—

BDAID: Crohn’s disease/UC

Entyvio

$0.41

$0.59

$0.14

$6,564

$6,498

$7,374

-6%

-26%

Bone resorption inhibitors (osteoporosis) Bone resorption inhibitors (osteoporosis)

Xgeva/Prolia

$1.30

$1.74

$0.01

$1,745

$1,728

$1,782

21%

51%

Evenity

$0.56

$0.69

$0.00

$2,467

$2,498

$1,779

52%

51%

-72%

Botulinum toxins

Botox

$0.28

$0.68

$0.00

$1,048

$941

$799

18%

-46%

Hematology: MG

Vyvgart

$0.43

$0.48

$0.08

$12,982

$10,066

$13,238

26%

70%

-29%

Immune globulin

Gammagard Liquid

$1.03

$0.43

$0.15

$2,639

$2,576

$3,497

43%

-14%

Immune globulin

Gamunex-C/ Gammaked

$0.45

$0.26

$0.15

$2,677

$4,230

$2,329

82%

-3%

Multiple sclerosis

Ocrevus

$0.62

$0.63

$0.12

$32,464

$29,340

$35,968

40%

-8%

Ophthalmic injections

Eylea

$0.37

$2.20

$0.00

$1,887

$1,848

—

-2%

-49%

—

Ophthalmic injections

Vabysmo

$0.42

$1.76

$0.00

$2,383

$2,401

—

-3%

-30%

—

Rare disease

Reblozyl

$1.48

$0.61

$0.00

$12,273

$12,091

—

63%

43%

—

Rare disease

Amvuttra

$0.92

$0.13

$0.10

$130,639

$101,757

$126,298

122%

212%

—

Due to rounding, totals may not add up accurately. Entries represented by “ —” indicate no spend, whereas entries represented by “$0.00” indicate spend less than $0.01.

2026 MEDICAL PHARMACY TREND REPORT 49

CO M M E R C I A L

MEDICARE

MEDICAID

20 2 5 M E D I C A I D TO P 2 5 D R U G P M P M S P E N D BY S I T E O F C A R E Figure 124

Therapy

Brand

Oncology

PMPM

Cost per claim

Utilization trend (2024–2025)

Hospital OP

Physician

Home

Hospital OP

Physician

Home

Hospital OP

Physician

Home

Keytruda

$1.51

$0.53

$0.00

$12,746

$14,414

—

-1%

26%

—

Oncology

Opdivo

$0.48

$0.18

$0.00

$8,637

$12,345

—

21%

—

Oncology

Darzalex Faspro

$0.50

$0.15

$0.00

$9,016

$11,459

—

25%

21%

—

Oncology

Imfinzi

$0.23

$0.10

$0.00

$9,438

$11,728

—

23%

169%

—

Oncology

Enhertu

$0.20

$0.08

$0.00

$11,089

$12,217

—

19%

75%

—

Oncology

Tecentriq

$0.19

$0.08

$0.00

$10,359

$11,484

—

67%

—

Oncology

Perjeta

$0.16

$0.07

$0.00

$6,476

$8,733

—

-1%

—

Oncology

Blincyto

$0.10

$0.01

$0.13

$13,421

$41,813

$20,702

171%

—

55%

Antidepressants

Spravato

$0.01

$0.22

$0.09

$1,160

$1,426

$895

53%

110%

689%

Antihemophilics

Hemlibra

$0.00

$0.31

—

$25,767

—

52%

BDAID: Crohn’s disease/UC

Entyvio

$0.25

$0.15

$0.04

$6,854

$7,630

$6,539

24%

-6%

Botulinum toxins

Botox

$0.20

$0.32

$0.00

$1,128

$1,351

$995

18%

15%

-82%

CNS: rare diseases

Zolgensma

$0.31

$0.00

$2,474,100

—

95%

—

CNS: rare diseases

Spinraza

$0.27

$0.00

$120,538

—

Contraceptives

Nexplanon

$0.06

$0.22

$0.00

$1,062

$1,120

—

-5%

—

Contraceptives

Mirena

$0.08

$0.16

$0.00

$1,048

$1,125

$1,157

19%

—

Crysvita

$0.10

$0.04

$0.17

$12,646

$16,183

$17,232

-6%

3794%

34%

Enzyme replacement therapy Enzyme replacement therapy Enzyme replacement therapy

Vimizim

$0.06

$0.00

$0.16

$12,067

—

$24,978

71%

—

12%

Elaprase

$0.10

$0.00

$0.12

$21,086

—

$17,428

367%

—

HIV

Cabenuva

$0.16

$0.04

$0.05

$7,417

$7,158

$6,455

149%

75%

57%

Immune globulin

Gammagard Liquid

$0.20

$0.07

$0.04

$2,420

$3,636

$3,863

21%

-24%

Multiple sclerosis

Ocrevus

$0.64

$0.27

$0.07

$30,561

$36,179

$21,792

15%

-10%

16%

Ophthalmic injections

Eylea

$0.03

$0.23

$0.00

$1,982

$2,031

$1,742

-27%

-7%

-72%

Rare disease

Elevidys

$0.56

$0.00

$2,973,167

—

46%

—

Vaccine

Prevnar 20

$0.05

$0.22

$0.00

$183

$257

$167

10%

17%

-35%

Due to rounding, totals may not add up accurately. Entries represented by “ —” indicate no spend, whereas entries represented by “$0.00” indicate spend less than $0.01.

CO M M E R C I A L

MEDICARE

MEDICAID

$622,000

$596,000

Vimizim

$691,000

Elaprase

Altuviiio

$697,000

$871,000

Alprolix

$465,000

Hemlibra

$756,000

$471,000

Tecartus

Vyjuvek

$496,000

CompleteFT

Kymriah

$508,000

Ilaris

Vyondys 53

$516,000

Soliris

Zolgensma

$545,000

Givlaari

Elevidys

$566, 000

Carvykti

PMPM

Danyelza

ACApatch

$1,042,000

Nexviazyme

$777,000

Xyntha

PMPM

$918,000

$1,290,000

Gamifant

$1,411,000

$1,626, 000

$1,317, 000

$1,380,000

Lamzede

Xenpozyme

Zolgensma

$0.09 $0.33 $0.06 $0.24 $0.06 $0.06 $0.06 $0.05

Elevidys

$0.11

Kalbitor

$0.19

Kanuma

$0.05 $0.14 $0.04 $0.37 $0.05 $0.04 $0.03 $0.02 $0.07 $0.05

Hemgenix

Amondys 45

$1,416,000

Brineura

$1,587,000

$1,791,000

$2,474,000

$2,769,000

$2,973,000

$3,123,000

$3,235,000

$3,500,000

20 2 5 TO P 1 0 H I G H EST- CO ST M E D I C A L B E N E F I T D R U G S BY A L LOW E D A M O U N T P E R U T I L I Z E R* Figure 125

$0.05 $0.14 $0.04 $0.37 $0.05 $0.04 $0.03 $0.02 $0.07 $0.05

PMPM

*Drugs administered in the hospital inpatient setting are not included in analyses. Annual allowed cost per utilizer rounded to the nearest thousand.

2026 MEDICAL PHARMACY TREND REPORT 51

CO M M E R C I A L

MEDICARE

MEDICAID

20 2 5 M A R K E T S H A R E T R E N D S : TOTA L R A R E D I S E AS E TEPEZZA

E L E V I DYS

AMVUTTRA

SPINRAZA

R E B LOZ Y L

V YJ U V E K

GIVLAARI

OT H E R*

CO M M E R C I A L Figure 126

M E D I C A R E Figure 127

M E D I C A I D Figure 128

MARKET SHARE

1.3%

2024

1.5%

52.6%

12.0%

2025

13.1%

13.0% 7.0%

77.4%

10.3%

15.0%

2.9% A N N UA L CO ST P E R U T I L I Z E R

19.8%

73.8%

4.8%

2024

2025 $325,665

Tepezza

$261,244

Elevidys

$2,461,861

$2,769,100

Elevidys

Amvuttra

$426,522

$350,056

Amvuttra

$385,025

Spinraza

$477,513

$410,990

Spinraza

Reblozyl

$174,262

$171,277

Reblozyl

Vyjuvek

$591,021

$652,330

Givlaari

$422,999

Other

$1,132,321

2024

2025

$295,902

Tepezza

$240,605

$286,870

Elevidys

$3,257,600

$2,973,167

$265,994

Amvuttra

$109,561

$370,653

Spinraza

$216,151

$255,257

$117,489

$129,102

Reblozyl

$113,623

$112,562

Vyjuvek

$753,915

$756,276

$445,550

Givlaari

$430,718

$544,770

Givlaari

$131,344

$132,571

$1,009,393

Other

$15,366

$159,986

Other

$1,538,937

$1,942,650

2024

A L LOW E D A M O U N T P M P M $0.12

$0.42

$0.09

$0.10 $0.21

A L LOW E D A M O U N T P M P M

Total: $1.82

Total: $2.53 $0.37

Total: $3.67

$0.43 $2.10

$1.44

2024

$1.16 $0.03

$0.10

Total: $1.52

$0.42

2024

2025

$0.49

$0.02

$0.14

$0.22

2024

Total: $1.78

$0.56

$0.27 $0.01

2025

$0.18

$0.25

$0.40

$0.12

*Other includes: Amondys 45, Exondys 51, Gamifant, Zolgensma and Vyondys 53.

$0.31

$0.54

$0.50

$0.16

$0.06

$0.17 $0.07

3.7%

Brand

$0.04

$0.04 $0.03

25.9%

2025

A L LOW E D A M O U N T P M P M

$0.05

31.5%

7.4%

A N N UA L CO ST P E R U T I L I Z E R

$360,548

$0.06

5.6%

1.9%

1.1%

Tepezza

$0.69

6.9%

5.6%

18.5%

Brand

Total: $1.73

2025

6.9%

22.4%

1.7%

0.5%

A N N UA L CO ST P E R U T I L I Z E R

$0.49

27.6%

0.9%

11.2%

3.4%

3.4% 27.6%

2025

2.3%

2024

1.7%

2.7%

3.6% 41.6%

12.0%

13.5%

4.4%

2024

$0.10

$0.02

2025

CO M M E R C I A L

MEDICARE

MEDICAID

20 2 5 M A R K E T S H A R E T R E N D S : TOTA L H E M ATO LO GY U LTO M I R I S

V Y VG A RT H Y T R U LO

N P L AT E

V Y VG A RT

SOLIRIS

UPLIZNA

A DA K V EO

OT H E R

CO M M E R C I A L Figure 129

M E D I C A R E Figure 130

M E D I C A I D Figure 131

MARKET SHARE

2024

3.6%

5.0%

16.5%

33.8%

3.1%

2024 2.5%

10.4% 7.1%

17.2%

12.9%

20.2%

42.9%

6.1%

6.3%

2025 15.5%

36.3%

2025

9.1%

17.1%

3.9%

4.9%

15.1%

20.0%

37.6%

A N N UA L CO ST P E R U T I L I Z E R

12.7%

A N N UA L CO ST P E R U T I L I Z E R 2024

13.9%

11.3%

41.7%

11.3%

18.3%

2.6%

0.9%

2025 15.7%

39.1%

11.3%

8.7%

13.9%

1.7%

4.3%

5.2%

3.9% 2.0%

3.7% 4.7%

Brand

9.8%

2.5%

4.2% 9.4%

2024

A N N UA L CO ST P E R U T I L I Z E R

2025

Brand

2024

2025

Brand

2024

2025

$262,650

$352,007

Ultomiris

$189,871

$194,797 $179,892

Ultomiris

$383,911

$424,335

Ultomiris

Vyvgart Hytrulo

$196,916

$322,180

Vyvgart Hytrulo

$177,366

$264,716

Vyvgart Hytrulo

$16,698

Nplate

$83,300

$74,197

Nplate

$41,559

$48,828

Nplate

$41,876

$39,880

Vyvgart

$243,748

$294,873

Vyvgart

$196,721

$206,315

Vyvgart

$53,335

$233,725

Soliris

$348,336

$478,561

Soliris

$352,152

$357,792

Soliris

$120,962

$127,716

Uplizna

$324,626

$296,904

Uplizna

$317,131

$296,417

Uplizna

$141,492

Adakveo

$83,452

$93,974

Adakveo

$68,015

$120,113

Adakveo

$61,032

$40,436

Other

$53,542

$53,460

Other

$8,905

$32,733

Other

$11,640

$34,478

A L LOW E D A M O U N T P M P M $0.05

$0.08

$0.04 $0.12

$0.11 $0.57 $0.22

A L LOW E D A M O U N T P M P M

Total: $1.60

$0.09

$0.22

$0.65

$0.18

$0.26

Total: $1.89

$0.23 $0.26

$0.25

$0.29

$0.04

$0.02

$0.28

$0.76 $0.49

A L LOW E D A M O U N T P M P M $0.06

Total: $2.92

$0.90

$0.34

$0.03 $0.02

$1.28

Total: $3.81

$0.10 $0.40

$0.05 $0.02

$0.10

$1.00

$0.10

$0.31 $0.44

$0.01

Total: $0.51 $0.13

$0.08 $0.20 $0.07

$0.03

Total: $0.64 $0.11

$0.22

$0.07

$0.09

2024

2025

2024

2025

2024

2025

2026 MEDICAL PHARMACY TREND REPORT 53

CO M M E R C I A L

MEDICARE

MEDICAID

20 2 5 M A R K E T S H A R E T R E N D S : S Q A N D I M M U N E G LO BU L I N S G A M M AG A R D L I QU I D

G A M U N E X- C /G A M M A K E D

PRIVIGEN

O C TAG A M

HIZENTRA

GAMMAPLEX

CUVITRU

CO M M E R C I A L Figure 132

M E D I C A R E Figure 133

M E D I C A I D Figure 134

MARKET SHARE

4.0%

2024 30.6%

19.7%

14.1%

12.4%

8.2%

0.7% 5.6%

2024 42.0%

8.5%

14.9%

16.9%

29.4%

22.1%

14.7%

12.8%

7.2%

0.8% 4.8% 40.6%

8.1%

19.4%

18.0%

23.6%

20.3% 5.9% 1.3%

2025

3.0% 2.4% 33.5%

10.5%

26.3%

26.3% 5.0% 3.5%

4.9% 1.0%

2.6% A N N UA L CO ST P E R U T I L I Z E R

41.0% 5.6% 1.3%

2025

3.1%

4.4% 0.3% 3.3%

2024

12.9%

2.5%

2025

OT H E R*

A N N UA L CO ST P E R U T I L I Z E R

Brand

2024

2025

Gammagard Liquid

$56,850

$59,048

Gammagard Liquid

$34,648

Gamunex-C/Gammaked

$57,480

$55,393

Gamunex-C/Gammaked

$40,706

Privigen

$65,693

$69,657

Privigen

$26,206

Octagam

$63,048

$61,045

Octagam

$21,711

$27,836

Octagam

$13,131

$19,862

Hizentra

$60,805

$73,241

Hizentra

$49,840

$59,882

Hizentra

$38,635

$35,800

Brand

2024

2025

Brand

2024

2025

$31,983

Gammagard Liquid

$32,430

$31,578

$35,713

Gamunex-C/Gammaked

$29,264

$27,150

$24,237

Privigen

$22,795

$22,003

Gammaplex

$93,039

$93,142

Gammaplex

$41,290

$55,705

Gammaplex

$22,838

Cuvitru

$72,346

$79,085

Cuvitru

$65,805

$74,323

Cuvitru

$42,137

$35,216

Other

$76,639

$85,518

Other

$39,578

$42,332

Other

$25,536

$21,806

A L LOW E D A M O U N T P M P M

$0.03

$0.11

$0.09 $0.31

$0.18

A L LOW E D A M O U N T P M P M

Total: $3.03

$0.38 $0.45

2024

$0.43

Total: $3.54 $0.67 $0.56

2025

$0.46

Total: $3.53

$1.51

$0.36 $0.54

Total: $4.11

$0.63

$0.85

2024

2025

$0.02 $0.02 $0.05

$0.01 $0.02

$0.36

$0.29 $0.29

*Other includes: Gammagard SD/Carimune NF, HyQvia, Panzyga, Xembify and Bivigam.

$0.10

$0.01 $0.95

$0.29

$0.55

$0.05

$0.38

$0.16 $0.84

$0.24

$0.09 $0.23

A L LOW E D A M O U N T P M P M $0.25

$1.60

$0.02 $0.06

$0.12

Total: $0.73

$0.17

2024

$0.33

$0.17

Total: $0.80 $0.21

2025

$0.31

CO M M E R C I A L

MEDICARE

MEDICAID

20 2 5 M A R K E T S H A R E T R E N D S : O N CO LO GY S U P P O RT: LO N G -AC T I N G CO LO N Y- ST I M U L AT I N G FAC TO R S U D E N YC A

N E U L ASTA

FULPHILA

NYVEPRIA

CO M M E R C I A L Figure 135

M E D I C A R E Figure 136

M E D I C A I D Figure 137

MARKET SHARE

2024

4.3%

22.4%

43.0%

30.3%

7.0% 25.9%

37.2%

46.3%

5.7% 32.3%

36.1%

2025 39.8%

10.2%

24.9%

A N N UA L CO ST P E R U T I L I Z E R 2024

2024 25.9%

25.8%

2025 25.1%

A N N UA L CO ST P E R U T I L I Z E R Brand

6.2%

21.7%

2025 30.0%

2024

16.9%

36.1%

9.2%

37.8%

A N N UA L CO ST P E R U T I L I Z E R

2025

Brand

2024

2025

Brand

2024

2025

$6,679

$6,498

Udenyca

$6,098

$5,472

Udenyca

$16,231

$20,520

Udenyca

Neulasta

$27,505

$21,537

Neulasta

$5,150

$4,417

Neulasta

$8,265

$9,157

Fulphila

$10,270

$10,635

Fulphila

$5,621

$5,335

Fulphila

$5,898

$5,371

Nyvepria

$9,197

$13,040

Nyvepria

$3,502

$8,138

Nyvepria

$3,671

$4,055

A L LOW E D A M O U N T P M P M

$0.03

$0.06

$0.24

$0.21

Total: $1.28 $0.79

2024

A L LOW E D A M O U N T P M P M

$0.05

$0.01

$0.03

$0.17 $0.24

$0.38

Total: $1.06 $0.34

2025

$0.31

Total: $1.24 $0.50

2024

$0.06

$0.33

$0.27

Total: $1.15 $0.36

2025

$0.08

Total: $0.26

$0.08

Total: $0.25 $0.12

$0.10

2024

2025

2026 MEDICAL PHARMACY TREND REPORT 55

CO M M E R C I A L

MEDICARE

MEDICAID

20 2 5 M A R K E T S H A R E T R E N D S : O P H T H A L M I C I N J EC T I O N S EYLEA

VA BYS M O

EYLEA HD

AVAST I N

PAV B LU

OT H E R*

CO M M E R C I A L Figure 138

M E D I C A R E Figure 139

M E D I C A I D Figure 140

MARKET SHARE

2024 29.5%

2.7%

2024

3.6% 9.1%

44.4%

27.7%

13.5%

1.1%

2024

12.2%

45.0%

21.9%

12.4%

50.7%

20.1%

6.2%

2025

5.6%

24.8%

2025

3.5%

10.5%

43.7%

2.7%

18.1%

11.9%

10.5%

2025

3.7% 53.6%

1.4%

20.8%

11.5%

9.7%

45.1%

15.4%

7.5% A N N UA L CO ST P E R U T I L I Z E R

A N N UA L CO ST P E R U T I L I Z E R

Brand

2024

2025

Eylea

$9,174

$8,878

Eylea

$8,682

Vabysmo

$11,368

$12,292

Vabysmo

$11,744

Eylea HD

$11,866

$13,365

Eylea HD

$9,516

Brand

2024

2025

Brand

2024

2025

$6,637

Eylea

$8,634

$7,100

$9,761

Vabysmo

$9,751

$10,916

$10,381

Eylea HD

$9,763

$13,956

Avastin

$772

$829

Avastin

$320

$372

Avastin

$268

$256

Pavblu

$6,837

Pavblu

$1,665

$6,832

Pavblu

$9,067

Other

$4,097

$3,377

Other

$6,363

$4,739

Other

$3,439

$1,579

A L LOW E D A M O U N T P M P M

A L LOW E D A M O U N T P M P M $0.05

$0.30

$0.07 $0.08

Total: $0.97

$0.15 $0.52

Total: $1.03

$0.20 $0.26

2024

2025

*Other includes: Cimerli, Izervay, Lucentis, Ozurdex and Syfovre.

$0.04

$0.08

$0.07

$0.11

A L LOW E D A M O U N T P M P M

$1.17

$1.65

$0.43 $0.53

Total: $10.50

$2.99

$0.54 $5.03

$0.43 $0.59

$2.57

Total: $7.48

$0.11 $0.16

$0.02

Total: $0.56

$0.02 $0.10

2025

$0.31 $0.02

$2.19

2024

Total: $0.66

$0.04

2024

$0.15

2025

$0.26

CO M M E R C I A L

MEDICARE

MEDICAID

20 2 5 M A R K E T S H A R E T R E N D S : B DA I D S : R H E U M ATO I D A RT H R I T I S ORENCIA

SIMPONI ARIA

AC T E M R A

REMICADE

CIMZIA

OT H E R*

CO M M E R C I A L Figure 141

M E D I C A R E Figure 142

M E D I C A I D Figure 143

MARKET SHARE

2024

21.0%

21.8%

11.7%

13.3%

11.9%

20.3%

2.5%

17.4%

2025

16.1%

15.8%

2025

21.5%

21.4%

8.3% 11.9%

11.7%

A N N UA L CO ST P E R U T I L I Z E R Brand

18.2%

14.7%

13.4%

17.0%

9.9%

20.7%

17.1%

34.2%

33.1%

4.2%

2025

A N N UA L CO ST P E R U T I L I Z E R 2024

14.7%

32.5%

3.4%

16.1%

25.2%

4.6%

2024

18.1%

6.9%

15.6%

38.1%

A N N UA L CO ST P E R U T I L I Z E R

2025

Brand

2024

2025

Brand

2024

2025

$27,407

$29,309

Orencia

$22,493

$22,918

Orencia

$29,986

$30,126

Orencia

Simponi Aria

$12,181

$11,592

Simponi Aria

$9,954

$9,077

Simponi Aria

$7,832

$6,942

Actemra

$28,975

$27,287

Actemra

$19,353

$19,069

Actemra

$20,610

$20,784

Remicade

$14,793

$13,910

Remicade

$10,891

$9,403

Remicade

$8,895

$8,781

Cimzia

$14,405

$14,028

Cimzia

$16,933

$13,202

Cimzia

$12,631

$12,329

Other

$18,115

$15,861

Other

$8,503

$9,139

Other

$9,722

$9,146

A L LOW E D A M O U N T P M P M

$0.21 $0.10 $0.11

Total: $1.11 $0.19

2024

A L LOW E D A M O U N T P M P M

$0.24 $0.35 $0.10 $0.15

$0.33

Total: $1.12

$0.39

$0.20

Total: $1.69

$0.10 $0.14

$0.15

2025

$0.38

$0.56

$0.05

$0.36

2024

A L LOW E D A M O U N T P M P M

$0.05 $0.17 $0.19

Total: $1.68 $0.31

2025

$0.02 $0.02 $0.20

$0.09

$0.57

Total: $0.38 $0.12

2024

$0.04

$0.10

$0.02 $0.02

$0.12

Total: $0.39 $0.04 $0.10

2025

*Other includes: Ruxience, Rituxan, Truxima, Tyenne, Inflectra, Renflexis and Avsola.

2026 MEDICAL PHARMACY TREND REPORT 57

CO M M E R C I A L

MEDICARE

MEDICAID

20 2 5 M A R K E T S H A R E T R E N D S : B DA I D S : C R O H N ’ S D I S E AS E / U LC E R AT I V E CO L I T I S ENTYVIO

REMICADE

SKYRIZI

I N F L EC T R A

RENFLEXIS

OT H E R*

CO M M E R C I A L Figure 144

M E D I C A R E Figure 145

M E D I C A I D Figure 146

MARKET SHARE

2024 32.6%

30.4%

5.8%

2024

3.0% 9.0% 10.0%

41.9%

15.0%

2024 9.5%

24.8%

11.8%

5.2%

22.8%

21.4%

30.6%

7.6%

12.4%

6.2%

2025

3.1% 28.6%

31.5%

12.6%

10.4%

2025 10.4%

24.4%

43.2%

13.7%

7.7% 9.0%

6.2%

23.8%

18.2%

27.2%

13.3%

11.3%

5.2% A N N UA L CO ST P E R U T I L I Z E R

A N N UA L CO ST P E R U T I L I Z E R

Brand

2024

2025

Entyvio

$48,926

$48,103

Entyvio

$39,235

Remicade

$19,649

$18,429

Remicade

$10,670

Skyrizi

$34,222

$41,527

Skyrizi

$20,928

Inflectra

$22,068

$23,070

Inflectra

$5,550

$7,614

Inflectra

$6,181

$7,092

Renflexis

$18,511

$17,081

Renflexis

$7,765

$8,278

Renflexis

$7,270

$7,480

Other

$33,829

$41,308

Other

$18,515

$22,019

Other

$13,626

$15,438

A L LOW E D A M O U N T P M P M

$0.08

$0.07

$0.70 $0.30 $0.42

Total: $4.53

$0.82

2024

2025

Brand

2024

2025

$35,228

Entyvio

$34,620

$34,079

$11,074

Remicade

$8,636

$8,205

$27,538

Skyrizi

$20,787

$25,360

A L LOW E D A M O U N T P M P M

$0.06 $0.03 $0.09

$0.80 $0.34

$2.20 $0.74

Total: $4.81 $0.74

2025

*Other includes: Avsola, Omvoh, Stelara SQ and Tremfya.

Brand

$2.13

$0.20

A L LOW E D A M O U N T P M P M $0.05 $0.03

$0.17

Total: $1.79

$0.21 $0.20

$0.10 $0.08 $1.14

2025

$0.03

$0.09

Total: $1.78

$1.25

2024

$0.02

$0.15

Total: $0.81

$0.10

2024

$0.10 $0.11 $0.42

Total: $0.93

$0.18 $0.08

2025

$0.44

CO M M E R C I A L

MEDICARE

MEDICAID

CO M M E R C I A L B DA I D T H E R A P Y: TO P P M P M S P E N D D R U G S* Figure 147 ENTYVIO

REMICADE

SKYRIZI

ORENCIA

ST E L A R A S Q

$2.09

$2.00 $1.64

I N F L EC T R A

$2.20 $2.13 (Entyvio)

$1.39

$1.53

$1.05

$0.35 $0.27 $0.09 2021

$0.74 (Remicade) $0.74 (Skyrizi) $0.39 (Orencia) $0.34 (Stelara SQ) $0.34 (Inflectra)

$0.82

$0.40

$0.49

$0.52

2022

2023

2024

2025

M E D I C A R E B DA I D T H E R A P Y: TO P P M P M S P E N D D R U G S* Figure 148 ENTYVIO

ORENCIA

AC T E M R A

SKYRIZI

REMICADE

SIMPONI ARIA

$1.25 $1.14 (Entyvio)

$0.96 $0.79 $0.61 $0.54 $0.27 $0.17 $0.16 2021

$0.50

$0.22

$0.27

2022

2023

$0.57 (Orencia) $0.31 (Actemra) $0.21 (Skyrizi) $0.20 (Remicade) $0.20 (Simponi Aria)

$0.56 $0.36

2024

2025

M E D I C A I D B DA I D T H E R A P Y: TO P P M P M S P E N D D R U G S* Figure 149 ENTYVIO

SKYRIZI

B E N LYSTA I V

ORENCIA

$0.41

ILARIS

I N F L EC T R A

$0.46

$0.42

$0.44 (Entyvio)

$0.37

$0.11

$0.09 $0.08 $0.05 2021

2022

$0.14

$0.13

2023

2024

$0.18 (Skyrizi) $0.13 (Benlysta IV) $0.12 (Orencia) $0.11 (Ilaris) $0.11 (Inflectra) 2025

*Some values may not be shown on graphs due to readability.

2026 MEDICAL PHARMACY TREND REPORT 59

Methodology The 2026 edition of the Prime Therapeutics Medical Pharmacy Trend Report was developed using 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 (2021–2025). The trend forecast used various modeling techniques, including time series modeling, product mapping, custom component modeling, assumption-based modeling and forecasting by analogy, to generate trends at a line-of-business level.

Health plan claims data Medical benefit drug utilization and trend data were collected through secondary analyses of commercial, Medicaid and Medicare Advantage health plan medical paid claims data for the most recent calendar years. Claims data were analyzed for medical pharmacy utilization across 1,433 Healthcare Common Procedure Coding System (HCPCS) codes and several outpatient sites of care.* Analyses compared medical claims data from 2025 to data from 2024. In some

Based on a spring 2026 survey of payers, this report provides a comprehensive view of payer perspectives and health plan approaches to managing provideradministered infused and injectable therapies under the medical benefit. These therapies are frequently used to treat chronic, progressive and life-altering conditions.

cases, the past five years were analyzed to show a longer period of year-overyear spend and trend. All data includes allowed amount costs directly from health plans for medical drugs only. Administration codes were analyzed separately and discussed on Page 38. *Items excluded were diagnostic radiopharmaceuticals and drugs administered in the inpatient hospital setting.

M E D I C A L B E N E F I T D R U G E X A M P L ES FO R T H E R A P E U T I C C L AS S ES Figure 150

Drug category

Example drugs**

Biologic drugs for autoimmune disorders (BDAIDs)

Cimzia, Entyvio, Orencia, Remicade

Hematology

Rystiggo, Soliris, Ultomiris, Vyvgart

Immune globulin

Gammagard, Gamunex, Hizentra, Privigen

Multiple sclerosis

Ocrevus, Rituxan, Tysabri

Oncology

Darzalex Faspro, Imfinzi, Keytruda, Opdivo

Oncology support

Antiemetics, CSFs, ESAs

Ophthalmic injections

Avastin (compounded/repackaged), Eylea, Lucentis, Vabysmo

Rare disease

Amvuttra, Spinraza, Tepezza, Zolgensma

**Not an inclusive list

Glossary and references aHUS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . atypical hemolytic uremic syndrome

MFP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . maximum fair price

AI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . artificial intelligence

MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . myasthenia gravis

AS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ankylosing spondylitis

Mix. . . . interaction between components of change and other components not otherwise captured

ASP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . average sales price

MS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . multiple sclerosis

ATTR-CM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . transthyretin amyloid cardiomyopathy

NMOSD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . neuromyelitis optica spectrum disorder

AWP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . average wholesale price

NSCLC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . non-small cell lung cancer

BDAIDs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . biologic drugs for autoimmune disorders

OP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . outpatient

CMS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Centers for Medicare & Medicaid Services

PMPM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . per member per month

CNS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . central nervous system

PNH. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . paroxysmal nocturnal hemoglobinuria

COLO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . colorectal

PS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . psoriasis

COVID-19. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . coronavirus disease of 2019

PSA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . psoriatic arthritis

Crohn’s/UC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Crohn’s disease/ulcerative colitis

RA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . rheumatoid arthritis

EGFR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . epidermal growth factor receptor

RAI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . rare autoinflammatory conditions

FDA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . U.S. Food and Drug Administration

Reimbursement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . changes in the level of provider reimbursement,

HCPCS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Healthcare Common Procedure Coding System

provider mix and site-of-care mix (relative to ASP)

HD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . high dose

SCLC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . small cell lung cancer

HER2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . human epidermal growth factor receptor 2

SQ. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . subcutaneous

IG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . immune globulin

UC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ulcerative colitis

Inflation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ASP/AWP price changes on a per-unit basis

Utilizers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . number of unique utilizers

IV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . intravenous

VEGF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vascular endothelial growth factor

LOB. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . line of business

YOY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . year-over-year

Reference

Page

Citation

U.S. Food and Drug Administration. (2021, July 26). FDA approves pembrolizumab for high-risk early-stage triple-negative breast cancer. https://www.fda.gov/drugs/resources-informationapproved-drugs/fda-approves-pembrolizumab-high-risk-early-stage-triple-negative-breast-cancer

U.S. Food and Drug Administration. (2025, January 27). FDA approves fam-trastuzumab deruxtecan-nxki for unresectable or metastatic HR-positive, HER2-low or HER2-ultralow breast cancer. https://www.fda.gov/drugs/resources-information-approved-drugs/fda-approves-fam-trastuzumab-deruxtecan-nxki-unresectable-or-metastatic-hr-positive-her2-low-or-her2

U.S. Food and Drug Administration. (n.d.). Oncology (Cancer)/Hematologic malignancies approval notifications. https://www.fda.gov/drugs/resources-information-approved-drugs/oncologycancerhematologic-malignancies-approval-notifications

Janssen Biotech, Inc. (2025). RYBREVANT FASPRO (amivantamab and hyaluronidase-lpuj) prescribing information. https://www.rybrevant.com/

Amgen Inc. (n.d.). DLL3-targeting BiTE therapy for 2L ES-SCLC. Retrieved July 15, 2026, from https://www.imdelltrahcp.com/

U.S. Food and Drug Administration. (2024, July 30). FDA approves daratumumab and hyaluronidase-fihj with bortezomib, lenalidomide, and dexamethasone for multiple myeloma. https://www.fda. gov/drugs/resources-information-approved-drugs/fda-approves-daratumumab-and-hyaluronidase-fihj-bortezomib-lenalidomide-and-dexamethasone-multiple

U.S. Food and Drug Administration. (2026, January 27). FDA approves daratumumab and hyaluronidase-fihj with bortezomib, lenalidomide, and dexamethasone for newly diagnosed multiple myeloma. https://www.fda.gov/drugs/resources-information-approved-drugs/fda-approves-daratumumab-and-hyaluronidase-fihj-bortezomib-lenalidomide-and-dexamethasone-newly

2026 MEDICAL PHARMACY TREND REPORT 61