The Silent Climb: Specialty Drugs in Workers’ Compensation
The workers’ compensation landscape is quietly shifting under the weight of high-cost specialty drugs. As these therapies redefine treatment, payers are scrambling to rein in costs, balance access, and keep claims from spiraling out of control.
The rules of the game in workers’ compensation are changing fast. Specialty drugs, once a niche concern, are now at the center of the action—driving costs, influencing policy, and forcing a recalibration of how payers and PBMs manage care. If 2024 was a warm-up, 2025 is shaping up to be the main event.
The Specialty Drug Pipeline
Brace yourself: specialty drugs are expected to make up 65% of new drug launches in 2025. While they bring groundbreaking treatment options, they also carry eye-watering price tags. Here’s how the spending forecast is stacking up:
Traditional Drugs:
2024–2025: 8.5% to 9.5% increase
2025–2026: 8.0% to 9.0% increase
Specialty Drugs:
2024–2025: 5.5% to 9.5% increase
2025–2026: 6.5% to 10.5% increase
With costs mounting, payers should be digging in, searching for ways to manage the financial fallout while keeping workers on the path to recovery.
Specialty Drugs: The Big Players in Workers’ Comp
1. Non-Opioid Pain Management
The opioid crisis forced a pivot, and now non-opioid alternatives like Suzetrigine® are emerging as viable solutions. These therapies promise pain relief without the baggage of addiction risk, making them a priority for payers. Read our previous spotlight on Suzetrigine.
2. Biosimilars: Oncology and Inflammatory Conditions
The biosimilar revolution is here, and it’s cutting deep into traditional drug monopolies. Cancer treatments like Kanjinti®and Trazimera® (biosimilars of Herceptin) are making oncology care more affordable, while biosimilars for Humira®and Stelara® are reshaping the inflammatory disease space. Read our previous spotlight on biosimilars.
3. High-Cost Pulmonary Medications
Asthma and COPD treatment costs are climbing, with drugs like Tezspire® and Fasenra® dominating formularies. The latest entrant, Alyftrek™, is shaking things up with a premium price tag of $370,000 annually—proof that innovation isn’t always a cost-cutter.
4. HIV Medications: The Shift to Long-Acting Agents
Single-tablet HIV treatments like Biktarvy® and Genvoya® still lead the market, but long-acting injectables for prevention and treatment are gaining traction. The trade-off? Convenience comes at a higher cost, adding another layer of complexity to formulary decisions.
Strategies to Tame the Beast
As these high-cost drugs take center stage, it is time to for payers rethink their old playbooks. Here are some new plays to consider:
Biosimilar Adoption: Expect broader formulary shifts favoring biosimilars over branded biologics to curb runaway costs.
Cost Plus Pricing: Payers should push their PBMs for pricing models that eliminate spread pricing and rebate games, ensuring they’re not overpaying for critical meds.
Specialty Drug Management: Partner with a PBM that brings both expertise and tenacity to tackle high-cost therapies with advanced clinical management—going beyond standard utilization controls and prior authorizations. Explore Specialty Nexus, a program designed to carve out specialty drugs from traditional formularies, placing them in the hands of experts who can drive savings of up to 35%.
Patient Education Initiatives: Getting patients actively involved in their health journey so they stick with prescribed treatments is half the battle. Find a partner that can ramp up engagement efforts to prevent claim delays and setbacks.
The Takeaway: A Balancing Act in 2025
Specialty drug costs will be a test of the industry’s ability to balance cost containment with cutting-edge treatment access. Employers, insurers, and PBMs must collaborate to keep workers’ comp sustainable while ensuring injured employees receive the best possible care.
As specialty drugs continue their rise, one thing is clear: the industry must evolve, or risk getting swallowed by the tide of high-cost innovation.
By Meghan Bannow
PharmD Candidate (P4)
For questions, e-mail pharmd@prodigyrx.com
Citations:
[1] https://www.goodrx.com/drugs/news/upcoming-fda-approvals
[4] https://www.smithrx.com/blog/4-pbm-trends-in-2025
[6] https://www.nfp.com/insights/biosimilars-2025-and-beyond/
[7] https://www.mercer-government.mercer.com/our-insights/2024_DrugTrendAndPipeline.html
[8] https://www.drugs.com/availability/generic-sprycel.html
[9] https://www.delveinsight.com/blog/hiv-1-treatment-market
[10] https://www.fiercepharma.com/marketing/top-10-most-anticipated-drug-launches-2025.com