Price Wars, Aetna Mental Health Suit, A Big Beautiful Analysis of HR1

Hey all,

happy hump day! I’m surprised by how many plans I see filling Humira while numerous biosimilars exist. It’ll be interesting to see how much plans push members on Stelara to use biosimilars. Enjoy the rundown! 

Jacob Brody (Co-Founder & CEO, ZorroRX)

(Drug Channels) Stelara Biosimilar Price War

The 2025 launch of Stelara biosimilars has ignited a competitive pricing war, with major PBMs—CVS Caremark, Express Scripts, and Optum Rx—leveraging private-label strategies and exclusive formularies to control costs and maximize rebates. Unlike the glorious chaos of the Humira biosimilar rollout—where coordination went to die—PBMs came to the Stelara market armed with vertically integrated house brands and a game plan. As CMS prepares to flex its price-setting muscles in 2026 under the Inflation Reduction Act, it now faces a biosimilar market so stuffed with “competition” (largely run by the same three players) that it might make government intervention look redundant—or just late to the party. Full Article

(BenefitsPro) Anthem Sued Over Mental Health Parity Violations

Anthem Blue Cross Blue Shield and several self-funded benefit plans are facing a lawsuit alleging violations of the Mental Health Parity and Addiction Equity Act by underpaying out-of-network mental health and substance abuse treatment claims. Filed by treatment provider All Points North, the suit highlights growing concerns over insurance practices that may reduce access to essential behavioral health care, particularly in underserved areas of Colorado; the case could have far-reaching implications for both ERISA and non-ERISA plans amid evolving legal interpretations of mental health parity. But sure—even though I can never find an in-network therapist, I’d be totally shocked if Anthem was dodging mental health parity laws. Full Article.

(Employer Coverage) Potential impact of Budget Bill (HR1) on employer-sponsored health insurance

 The newly enacted HR1 budget bill significantly cuts Medicaid and fails to extend ACA exchange subsidies, potentially pushing millions off public coverage and increasing pressure on employer-sponsored health insurance. With an estimated 8.7 million losing Medicaid and 11 million dropping Marketplace plans, employers may face higher costs and growing demand for coverage, especially in rural or underserved areas where care access could worsen. Some relief comes through provisions allowing HSA payments for direct primary care and continued pre-deductible telehealth coverage, while other employer-favorable proposals were removed in the Senate. I hope this will incentivize more employers to adopt direct primary care and other subscription-based longitudinal care models to improve access and manage rising costs. Full Article.