The healthcare landscape in the United States is poised for significant changes in 2025.

With a new administration in the White House and the anticipated confirmation of new heads of the Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), Centers for Disease Control and Prevention (CDC), and Food and Drug Administration (FDA), we expect the industry to continue evolving at a rapid pace, with changes in regulatory frameworks, advancements in innovation, and shifts in patient expectations shaping payer priorities. Payer organizations must adapt to these shifts while maintaining cost-effectiveness, quality of care, and operational efficiency.

This report by Nexus Health Group outlines 6 payer-focused trends to watch in 2025, helping organizations stay ahead in a complex, rapidly evolving, and competitive healthcare environment.

For this report, the Nexus team surveyed 17 payers, including pharmacy and medical directors. Plan sizes ranged from 500,000 to more than 5 million lives, with approximately 60% of payers representing over 5 million covered lives.

Trend 01

Oncology, CGT, and specialty drug spend remain top payer priorities in 2025.

When asked about the biggest priorities payers were facing moving into 2025, most are focused on specialty drug spend, with oncology drug spend, cell and gene therapies, and overall specialty drug spend as the top 3 priorities for 2025. Glucagon-like peptide-1 (GLP-1) management followed closely behind as a 2025 priority.

Trend 02

Payers are seeking better value for healthcare spend.

In 2025, decision-makers are confronting several critical challenges. Top concerns for payers included drug utilization and costs associated with trend and affordability. With rising healthcare costs, overall healthcare expenses are prompting payers to seek better value for healthcare dollars. GLP-1 management for obesity came in second as a top concern, especially as new options emerge, and the category continues to grow. Policy uncertainties filled out the list, with payers noting the impact of the IRA on Medicare, as well as the pharmacy benefit manager (PBM) regulatory environment as concerns for their organizations.

Trend 03

Management of key therapeutic areas will be a major focus for payers in 2025.

Payers are actively managing or considering management strategies for key therapeutic areas, each presenting unique challenges and opportunities.

Immunology ranks as the top priority for management (29.4%), driven by the high total drug costs of systemic therapies for inflammatory diseases. As new treatment options emerge, payers remain focused on cost management in this growing category.

Oncology follows closely as a primary focus (23.5%), with an expanding pipeline of clinical trials, novel therapies—including gene and CAR T-cell therapies—and advanced diagnostics. Payers must assess the efficacy, safety, and cost-effectiveness of these innovations.

For the second most important management category, payers equally prioritized cell and gene therapies (23.5%), diabetes (23.5%), and oncology (23.5%). The rise of cell and gene therapies is reshaping treatment paradigms, but payers face challenges in balancing their long-term benefits with their high costs.

The third-ranked management priorities include oncology (31.1%), obesity/weight loss medications (23.5%), and diabetes (17.7%). The growing prevalence of obesity and metabolic disorders has increased the focus on GLP-1 agonists and other weight management therapies, requiring payers to assess their cost-effectiveness and overall impact on healthcare spending.

Notably, rare disease was ranked as a fourth-tier management priority, despite the increasing number of high-cost therapies in this space.

Trend 04

Formulary size will remain stable while maximizing savings & rebate revenue.

Within these priority therapeutic areas identified by payers, over 35% indicated that their management has increased compared to last year, while roughly 65% indicated that their management has remained the same.

Trend 05

Medical benefit management is on the rise, mirroring pharmacy benefit management.

Payers are applying pharmacy benefit management tactics to medical benefit drugs as the pipeline shifts toward provider-administered biologics. This trend is expected to grow as more plans adopt similar management strategies.

Trend 06

Government & industry uncertainties are what’s keeping payers up at night.

With the new administration, payers are preparing for five key themes.

About Nexus Health

The Nexus Health Group provides an integrated, simplified approach to comprehensive market access strategies, offering solutions in strategic
consulting, value communications, and patient access and affordability. Nexus experts combine deep market access experience in complex therapies with a foundation in science to provide the strategic advantages manufacturers need to launch and differentiate their products in today’s marketplace. Launched in 2025, Nexus may be a new company, but with an average of 21+ years of experience, the team is far from new to market access.

Meet the authors