How National CooperativeRx Outpaced Industry Trend Benchmarks

In a year marked by significant shifts in the pharmacy benefit landscape, many organizations faced rising drug costs and complex decisions that could impact their bottom line. While industry trends projected increases between 7-10% in 2024, National CooperativeRx achieved an overall trend of just 5.6%, after rebates. This outcome is a testament to our industry expertise, clinical oversight, and member engagement—key factors that deliver exceptional results.

Adapting to Market Shifts: Industry Expertise

The pharmacy benefit landscape experienced substantial shifts in 2024, including the introduction of Humira biosimilars, reductions in insulin list prices, and the rise of glucagon-like peptide-1 agonists (GLP-1s). These shifts each required careful decision-making and strategic planning, which for many in the industry, could have been challenging without the right pharmacy benefit manager (PBM) partnerships, market intelligence, and a strong contract. At National CooperativeRx, we not only navigated these changes but turned them into opportunities to drive value for our members.

Humira

Humira, once the drug with the highest spend for our members, was replaced by cost-effective biosimilars. With CVS Caremark’s strategic decision to remove brand Humira from the formulary, nearly all our participants transitioned to the biosimilars, saving substantial costs for our members. As this shift occurred, we have positioned our contract to ensure maximum value for patients and plan sponsors, and used data analysis to validate the value is delivered.

Lower List Price, Lower Rebates

When insulin list prices decreased in 2024, and CVS Caremark shifted to a lower list price, lower rebate approach over a higher list, higher rebate model, National CooperativeRx quickly adapted. We negotiated strong rebate credit language into our PBM master contract, providing a robust rebate definition and limiting the use of rebate credits to situations that are proven to be in the best interest of patients and plan sponsors. This resulted in our members experiencing savings that exceeded the value of the rebate credits taken, reinforcing our decision to advocate for a future with lower list prices for plan participants.

GLP-1s

Given the evolving GLP-1 landscape, National CooperativeRx developed an optional custom strategy for our member groups, requiring a type 2 diabetes diagnosis to confirm use, especially in plans who do not cover weight loss drugs. Our custom strategy focuses on enforcing member groups’ coverage intent, minimizing off-label use, and ensuring appropriate quantities, which helps reduce waste. While an administrative fee applies to account for lost rebate value of decreased utilization, this continues to be an option for our members.

Our Contract Agility

A major component of our success is the flexibility of our PBM master contract. With one master contract, we can adapt to industry shifts and respond to emerging trends. To further maximize value, we hire independent auditors and perform annual market checks to ensure our contract terms stay competitive, reflect current market dynamics, and continue delivering optimal value to our membership.

Oversight: Clinical Programs and Fiduciary Duties

Our industry expertise, combined with our clinical oversight and guidance, creates a robust framework that effectively controls spend, delivers high-quality care, and provides member groups with peace of mind, knowing their interests are always at the forefront.

In-House Clinical Programs

Our clinicians have developed no-additional-cost clinical programs designed to eliminate misaligned incentives, improve quality of care, and reduce costs. These programs include:

• Supplemental Formulary Management
• High-Cost Claim Reviews
• Advanced Criteria Updates
• Pharmacy Network Oversight
• Specialty Prior Authorization Carveout

Our Specialty High-Cost Claim Reviews and Specialty Prior Authorization Carveout target specialty drug management and delivered impressive results in 2024—a $60 million cost avoidance for our members. As a result, our specialty trend after rebates was just 2.5%.

Supporting Fiduciary Duties

Transparency and accountability are at the core of our approach. We support plan sponsors in fulfilling their fiduciary duties by providing clear, actionable data and insights. Our members not only receive access to their data, but expert guidance on how to interpret and apply it to make informed decisions. With no conflicting interest, we ensure every decision is driven by what is best for our members and their plan participants.

Engaged and Empowered Members

Our members’ active engagement and collaboration with National CooperativeRx are the ultimate drivers of the positive outcomes we consistently achieve. With over 86% of our members participating in our in-house clinical programs, we have built trust in our expertise and recommendations. Through continuous education and tailored plan design suggestions, we work hand-in-hand with our members to help them implement effective strategies. Our annual client review meetings further strengthen these partnerships, enabling us to refine and optimize their plans, resulting in greater savings and improved care.