Excellus BCBS Broker News Vol. 20 No. 2 Special Issue

A Message from Mona Chitre

The year is off to an exciting start! As a pharmacy partner, we consistently monitor market trends to ensure our programs and solutions meet the specific needs of our groups.

We’re eager to share the many pharmacy opportunities and advancements that our team has started to track this year:

2025 Pharmacy Updates

• Stelara Biosimilars: Starting in January 2025, Amgen will launch the first Stelara biosimilar, Wezlana™, followed by up to six additional manufacturers in the first half of the year. Biosimilars play a critical role in controlling drug spend amidst rising health care costs driven by biologics. Our approach to formulary management focuses on always driving toward the lowest net cost. To ensure we make the most conscious and thorough evaluation, all Stelara biosimilars will be reviewed before any strategic decisions are made on formulary placement.
• Pharma Patent Cliff: Over the next several years, patents for 25 high-value drugs will lose their exclusivity, including Keytruda® and Eliquis®. Within 2025, drugs that could potentially lose exclusivity are Entresto, Farxiga, Prolia® and Xarelto®, opening the market to generic and biosimilar competition. This shift is expected to enhance treatment affordability and accessibility, significantly impacting the pharmaceutical landscape.
• FDA Denies Oclavia® Approval: The FDA has declined to grant full approval for Intercept Pharmaceuticals' liver disease drug, Ocaliva, for treating primary biliary cholangitis (PBC)¹. The decision was made due to concerns about the drug's safety, particularly the risk of serious liver injury in patients without cirrhosis. Our team has been actively monitoring the FDA’s decision to make sure we remain compliant with regulations, while ensuring member safety. Based on the available literature, we updated our policies to no longer allow new starts of the medication. We have also informed physicians with active prescriptions for members and advised them on alternatives.
• GLP-1 Landscape: As GLP-1 landscape continues to evolve we are actively making sure our policies align with the available data to ensure safe and effective outcomes for our members. As of 1/1/25, Excellus BlueCross BlueShield has revised the prior authorization criteria to align with bariatric surgery standards by increasing the required BMI. This decision was made with careful analysis to prioritize members at the highest risk of imminent medical and life-threatening complications. In 2024 Zepbound® had an expanded indication for sleep apnea and Wegovy® had an expanded indication for risk reduction of major adverse cardiovascular events. As of January 2025, Ozempic® is now approved to be used in type 2 diabetics with chronic kidney disease. Over the next few years, we expect to see approval of additional GLP-1 drugs along with new indications like heart failure for existing drugs and continue to closely monitor these trends.
• Specialty Drugs Creating Downstream Cost Savings: Specialty drugs, often criticized due to their high costs, are showing to have greater savings in the long term due to cost avoidance through reduced medical costs. Recently, a study² was published showing that specialty drugs for cystic fibrosis (CF) can significantly improve lung function in people with advanced lung disease. Additionally, the study highlights the positive impact of Trikafta® since it was approved in 2019, showing notable improvements in CF lung disease and potentially reducing the need for lung transplants. These findings could lead to better cost management and outcomes for patients with advanced CF lung disease. As a pharmacy partner, it’s important for us to have strategies in place to help guarantee appropriate utilization of these specialty drugs. We will work, as we always do, to ensure the medications we cover have been proven safe and effective for the condition being treated and demonstrate positive outcomes. As you know, everything begins with our mission. Helping people in our communities live healthier and more secure lives through access to high-quality, affordable health care guides everything we do and every decision we make. Our approach to pharmacy benefits is no exception. Learn more from our Pharmacy Value Story.

As you know, everything begins with our mission. Helping people in our communities live healthier and more secure lives through access to high-quality, affordable health care guides everything we do and every decision we make. Our approach to pharmacy benefits is no exception. Learn more from our Pharmacy Value Story.

As the area’s largest not-for-profit health plan, we believe our greatest responsibility is to deliver for the people, businesses and communities who count on us. We are committed to working together to bring greater access to high-quality, affordable care to the communities we serve.

Here’s to a successful year ahead,

Mona Chitre, CPO & President of Pharmacy Solutions

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^{1 Center. (2024). Serious liver injury being observed in patients without cirrhosis taking Ocaliva (obeticholic acid) to treat primary biliary cholangitis. U.S. Food and Drug Administration. Retrieved from FDA.}

^{2 "Impact of elexacaftor-tezacaftor-ivacaftor in lung transplantation for cystic fibrosis in the United States." JHLT Open, 2024.}

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