Insurers Reject 70% of New Brand Scripts, Part D Costs Explode 33% (Surprise!), and Lilly Files Its "Better Than Insulin" Results

Hey all,

Happy Thursday! It seems the pharmaceutical industry has finally perfected the "one step forward, two steps back" routine: we’re celebrating a new pill that protects your heart without ruining your morning espresso, while insurers have simultaneously turned the simple act of filling a script into a high-stakes endurance sport where 70% of participants are disqualified at the starting line. Between Eli Lilly’s latest clinical win and IQVIA’s data on skyrocketing coverage denials, it’s clear that while the science is moving at light speed, the administrative red tape is currently being managed by people who think "access" is a four-letter word. As Medicare costs surge and commercial payers tighten the screws, we’re left with the comforting reality that the only thing more certain than medical innovation is the distinct possibility you’ll need a legal team just to get your hands on it.

Enjoy the rundown!

Jacob Brody (Co-Founder & CEO, ZorroRX)

[IQVIA] Increasing Payer Control for Commercial Patients Initiating Branded Medicines

A new analysis reveals that 70% of all initial attempts to fill branded medicines under commercial insurance were rejected in 2025, representing a sharp 13 percentage point increase in coverage denials since 2021. This research confirms that nearly a quarter of new-to-brand claims are never approved within a year, leaving millions of patients in a state of perpetual administrative limbo while attempting to access physician-prescribed therapies. For those of us currently balancing a small collection of branded medications, the "news" that insurers are aggressively gatekeeping our health is about as shocking as discovering that water is wet or that the "prior auth" process is actually a carefully designed endurance sport for the chronically ill.

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[Milliman] MedIntel Part D trend insights

Full-year 2025 data reveals a dramatic 33% surge in gross drug costs for non-low income Medicare Part D members, largely driven by a 127% two-year spike in specialty drug spending following the introduction of the new maximum out-of-pocket cap. While GLP-1 medications have reached a record $66 PMPM and continue to lead class-level growth, the data suggests that the rapid cost acceleration seen mid-year began to moderate slightly in the fourth quarter. Since standard actuarial models are currently about as reliable as a weather forecast in a hurricane, insurers get the distinct pleasure of trying to decide if this financial dumpster fire is the "new normal" or just a one-time parting gift from the IRA.

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[Endpoints News] Lilly’s Foundayo Cardiovascular Trial and Diabetes Filing

Eli Lilly’s obesity pill, Foundayo, demonstrated a 16% reduction in major adverse cardiovascular events compared to insulin in the ACHIEVE-4 trial while showing no signs of hepatic toxicity. These clinical results fulfill a specific FDA safety data request and provide the foundation for the company to officially file for a new treatment indication in diabetes. While Lilly is currently playing catch-up with Novo Nordisk, Foundayo might just take the lead since it doesn't require users to skip their morning coffee—proving that in the world of pharma, the quickest way to a patient's heart (risk reduction) is through their caffeine addiction.

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