As the pharmacy landscape rapidly shifts under regulatory and cost pressures, working with an agile pharmacy partner to manage trend, access, and accountability in real time is vital.
Throughout this past year, Excellus BlueCross BlueShield has taken a more connected approach to best serve our clients and members by linking decisions across pharmacy, medical care, and benefit design.
High-cost specialty drugs, new biosimilars, and evolving pricing models are shaping how care is delivered and subsequently paid for by members and groups. Each area requires clear and careful examination when developing cost-savings solutions.
Following are three key pharmacy opportunities and innovations our team has focused on this year.
Managing specialty drug costs across the full benefit
For members with rare medical conditions, new specialty treatments may offer better control of serious symptoms. For members and groups, those treatments can also bring significant costs.
Generalized myasthenia gravis (gMG), a rare disease that causes muscles to weaken and tire quickly, offers a clear example of how fast specialty drug costs can rise. In May, the FDA approved new uses for Vyvgart® and Vyvgart Hytrulo®, one of the mainstays of treatment for gMG. The additional indications allow more adults with the disease to qualify for treatment, which is incredible for those who suffer from this disease. However, with these drugs potentially costing between $250,000 and $700,000 per patient each year, even a small increase in the number of eligible patients can have a large impact on healthcare spending.
To maintain access to effective treatment while managing rising costs, Excellus BCBS has implemented a strategy that prioritizes the most cost-effective therapy options. Vyvgart Hytrulo® prefilled syringe, which can be self-administered and is covered under the pharmacy benefit, offers a lower-cost alternative to other medications used to treat gMG.
Our coverage policy requires the use of Vyvgart Hytrulo® prefilled syringes through the pharmacy benefit before other medical or pharmacy benefit drugs used to treat gMG. This approach helps ensure members receive clinically appropriate care while creating meaningful savings opportunities for employers and health plans.
When the FDA approves a new drug or a new indication, we review the medical evidence, treatment guidelines, site of care, and whether drug coverage will fall under the medical or pharmacy benefit, or both. Managing these decisions helps us support the best and most cost-efficient care delivery model and reduce waste.
With specialty drugs continuing to drive an outsized portion of trend, other strategies are being explored to further reduce waste and optimize cost. For example, beginning January 1, 2027, certain specialty medications covered under the pharmacy benefit will move to a 30-day supply limit for applicable fully insured and minimum premium groups. Self-funded groups will have the option to elect this benefit design, which helps control specialty drug costs while maintaining access to needed care.
We are implementing a 30-day supply cap for specialty medications to improve medication management, reduce avoidable waste, and help mitigate long-term cost trends, while continuing to support members in accessing the therapies they need. Many specialty drugs can potentially have side effects or require adjustments. Limiting the day supply will minimize unnecessary expenses and reduce medication waste. In the majority of cases, a member's copay for the smaller supply will be less to match the smaller supply. In addition, this change supports trend mitigation, helping to control overall costs and limit future rate increases.
Making biosimilars part of standard practice
Biosimilars are a key part of medical management. They are highly similar to existing biologic drugs and meet the same stringent FDA standards for safety and results while typically costing less than the reference drug.
At Excellus BCBS, we continue to evaluate the biosimilar market and pipeline to ensure we are prioritizing the most high-quality, cost-effective medications for our members. In 2026, we have expanded our overall biosimilar strategy and added denosumab products, which are used to treat osteoporosis and certain cancers. The reference products Prolia® and Xgeva® now have biosimilar alternatives available in the market. As of August 1, 2026, preferred biosimilars became the standard option for members starting or continuing therapy.
For Prolia®, preferred biosimilars Bildyos™ and Enoby™ will be available without prior authorization. Other products, including Prolia®, will require prior authorization and step therapy that supports the use of preferred biosimilars first.
For Xgeva®, preferred biosimilars Bilprevda™ and Xtrenbo™ will require prior authorization for medical necessity review. Other products, including Xgeva®, will require prior authorization and step therapy requirements for both new and existing users.
This approach supports broader biosimilar adoption while helping manage drug costs across the medical and pharmacy benefits.
Bringing greater clarity to drug pricing
We understand that pharmacy contracts can be complex and the market is shifting to administrative fee-driven pricing models with low- or no-rebates factored into pricing. As we continue to evolve, we’re using feedback from our clients to improve our communication and transparency along with our client experience. Our goal is to give groups clear answers before questions arise to help them make informed choices about their pharmacy benefits.
By partnering with Excellus BCBS, our clients can trust that we will continue to show what is being paid, why it is being paid, and communicate when costs may change. The landscape may continue to shift rapidly as list prices change, rebates change, and new biosimilars become available. Our formularies are continually reviewed to optimize high-impact, lower-cost treatment options. Our members are always at the center of every decision we make. We will continue to communicate proactively as we evolve together towards a new model.
One connected strategy
Specialty drugs, biosimilars and drug pricing each impact access, cost, and the value groups receive from their benefits.
Our work connects medical review, benefit design, and clear pricing to help members get the care they need while helping groups manage costs.
This work supports healthier people, stronger communities, and more secure lives across New York State.
And when our members, groups and communities are stronger, everybody benefits.
With appreciation,
Excellus BlueCross BlueShield, Your Pharmacy Partner
ExcellusForBusiness.com Reminder
On ExcellusForBusiness.com you can access blog articles, case studies, and more to help find solutions and ways to manage the rapid shifts in the pharmacy landscape. Here are just a few of those helpful resources.
Save on specialty drug cost with an integrated approach
Maximizing HDHP pharmacy benefits
Reduced costs with Pharmacy Concierge
Keeping pharmacy services on track
