Specialty Complex Care: Cardiopulmonary, Hematology and Neurology Insights
Cardiopulmonary
Cardiopulmonary spend remains driven by a mix of leading cardiometabolic and specialty biologic therapies:
- Tafamidis (Vyndamax, Vyndaqel) continues to fuel growth in transthyretin amyloid cardiomyopathy.
- Sacubitril/valsartan (Entresto) and evolocumab (Repatha) remain essential for heart failure and hyperlipidemia management.
- Omalizumab (Xolair) leads across asthma and related allergic conditions, supported by broader payer coverage.
- Asthma biologics such as mepolizumab (Nucala), benralizumab (Fasenra), and tezepelumab (Tezspire) continue to gain traction, with Tezspire showing one of the higher projected price increases (8.0%).
- Trikafta remains the cornerstone therapy for cystic fibrosis, complemented by Pulmozyme for long-term disease management.
- Oral semaglutide (Rybelsus) recently gained FDA approval to reduce primary and secondary cardiovascular death in adults with type 2 diabetes at high cardiovascular risk, signaling continued expansion of cardiometabolic therapies.
Overall, growth is steady and sustained by specialty biologics and chronic cardiovascular agents.
| Rank | Generic Name | Brand Name(s) | Indication | % of Spend* | Price Projection |
|---|---|---|---|---|---|
| 1 | Omalizumab | Xolair | Asthma, chronic urticaria, nasal polyps | 0.71% | 0.0% |
| 2 | Tafamidis | Vyndaqel, Vyndamax |
Transthyretin amyloid cardiomyopathy | 0.46% | 7.0% |
| 3 | Elexacaftor / Tezacaftor / Ivacaftor | Trikafta | Cystic fibrosis | 0.45% | 2.0% |
| 4 | Mepolizumab | Nucala | Severe eosinophilic asthma | 0.31% | 3.0% |
| 5 | Lipase / Protease / Amylase | Creon, Zenpep, Pancreaze | Pancreatic enzyme replacement (CF, pancreatitis) | 0.27% | 3.3% |
| 6 | Tezepelumab-ekko | Tezspire | Severe asthma | 0.26% | 8.0% |
| 7 | Sacubitril / Valsartan | Entresto | Heart failure with reduced EF | 0.26% | 2.5% |
| 8 | Evolocumab | Repatha | Hyperlipidemia, ASCVD | 0.24% | 2.0% |
| 9 | Benralizumab | Fasenra | Severe eosinophilic asthma | 0.23% | 3.0% |
| 10 | Dornase alfa | Pulmozyme | Cystic fibrosis | 0.19% | 3.0% |
*Portion of spend for the NDCs making up the top 85% of Vizient pharmacy program participant spend Abbreviations: ASCVD = atherosclerotic cardiovascular disease; CF = cystic fibrosis; EF = ejection fraction
Cardiopulmonary pipeline: Anticipated high-impact approvals
| Drug Supplier |
Route | MOA | Indication(s) | Anticipated approval date |
|---|---|---|---|---|
| Etripamil Milestone |
Nasal | L-type calcium channel blocker | SVT including atrial fibrillation | 12/31/2025 |
| Nerandomilast Boehringer Ingelheim |
Oral | PDE4 inhibitor | ILD; IPF | 4Q 2025 |
| Plozasiran Arrowhead |
SubQ | Small interfering RNA | FVS; hypertriglyceridemia | 11/18/2025 |
Hematological therapies
Hematology spend balances high-use anticoagulants with costly rare disease therapies:
- Apixaban (Eliquis) remains the leading agent by spend share, reflecting consistent use in stroke prevention and VTE management.
- Thrombolytic utilization is shifting as institutions transition from alteplase to tenecteplase for stroke care due to easier administration and growing evidence support.
- Pegfilgrastim (Neulasta) remains central to oncology support, though biosimilar adoption continues to erode total spend.
- Complement inhibitors continue to drive rare disease costs, with Ultomiris displacing Soliris and expanding into neurology indications such as gMG and NMOSD.
- Emerging therapies like romiplostim (Nplate) for ITP and luspatercept (Reblozyl) for MDS and thalassemia broaden treatment options despite ongoing pricing scrutiny.
Overall trend: steady utilization across both acute and rare conditions, with the most pricing pressure on supportive care agents.
| Rank | Generic Name | Brand Name(s) | Indication | % of Spend* | Price Projection |
|---|---|---|---|---|---|
| 1 | Apixaban | Eliquis | Anticoagulant (stroke prevention, VTE treatment/prevention) | 0.87% | 0.0% |
| 2 | Ravulizumab-cwvz | Ultomiris | PNH, atypical HUS, myasthenia gravis | 0.64% | 2.0% |
| 3 | Alteplase | Activase, Cathflo Activase | Thrombolysis (ischemic stroke, MI, catheter clearance) | 0.63% | 2.5% |
| 4 | Pegfilgrastim | Neulasta | Neutropenia prevention (chemo-induced) | 0.55% | 0.0% |
| 5 | Eculizumab | Soliris | PNH, atypical HUS, generalized myasthenia gravis, NMOSD | 0.51% | 0.0% |
| 6 | Human Prothrombin Complex Concentrate | Kcentra | Urgent reversal of vitamin K antagonist anticoagulation | 0.43% | 0.0% |
| 7 | Tenecteplase | TNKase | Thrombolysis (acute myocardial infarction) | 0.38% | 6.0% |
| 8 | Coagulation Factor VIIa | NovoSeven | Hemophilia with inhibitors, bleeding episodes, perioperative management | 0.36% | 4.9% |
| 9 | Romiplostim | Nplate | Immune thrombocytopenia (ITP) | 0.35% | 10.0% |
| 10 | Luspatercept-aamt | Reblozyl | Anemia in β-thalassemia and MDS | 0.26% | 4.0% |
*Portion of spend for the NDCs making up the top 85% of Vizient pharmacy program participant spend
Abbreviations: HUS = hemolytic uremic syndrome; ITP = immune thrombocytopenia purpura; MDS = myelodysplastic syndrome; MI = myocardial infarction; NMOSD = neuromyelitis optica spectrum disorder; PNH = paroxysmal nocturnal hemoglobinuria; VTE = venous thromboembolism
Hematologic therapy pipeline: Anticipated high-impact approvals
| Drug Supplier |
Route | MOA | Indication(s) | Anticipated approval date |
|---|---|---|---|---|
| Mitapivat (Pyrukynd) Agios |
Oral | Allostatic activator of pyruvate kinase-R | Alpha or beta thalassemia | 12/7/2025 |
Neurology
Neurology spend continues to be led by therapies for multiple sclerosis (MS), migraine, and spasticity, with biologics and novel oral agents driving much of the category’s innovation and growth. OnabotulinumtoxinA (Botox) remains widely used across migraine and spasticity, while the migraine segment continues to expand with newer acute and preventive agents such as rimegepant (Nurtec), ubrogepant (Ubrelvy), and eptinezumab (Vyepti). Collectively, these products are reshaping the standard of care by improving access to targeted, mechanism-based therapies. Adoption of efgartigimod (Vyvgart) has also accelerated as prescribers embrace FcRn-targeted immunotherapy for myasthenia gravis, signaling the growing influence of precision biologics in neuromuscular disease management.
In multiple sclerosis, high-cost disease-modifying therapies continue to dominate spend, led by ocrelizumab (Ocrevus) and ofatumumab (Kesimpta), both of which maintain strong payer coverage and provider confidence. The introduction of Ocrevus Zunovo, a subcutaneous formulation co-formulated with hyaluronidase, is expected to improve convenience and broaden site-of-care options. Looking ahead, the MS landscape is poised for significant change with upcoming biosimilar launches and the anticipated entry of Bruton’s tyrosine kinase (BTK) inhibitors, including tolebrutinib, which has a PDUFA date in December 2025. Natalizumab-sztn (Tyruko) is also expected to enter the market by late 2025, marking the first MS biosimilar and signaling the start of a new competitive era.
Overall, neurology remains a rapidly evolving category characterized by expanding biologic and small-molecule innovation, increasing site-of-care flexibility, and steady spend growth across chronic and complex neurologic diseases.
| Rank | Generic Name | Brand Name(s) | Indication | % of Spend* | Price Projection |
|---|---|---|---|---|---|
| 1 | Ocrelizumab | Ocrevus (not including Ocrevus Zunovo) | Multiple sclerosis (relapsing and primary progressive forms) | 1.67% | 5.0% |
| 2 | OnabotulinumtoxinA | Botox | Chronic migraine, spasticity, cervical dystonia, other neurologic disorders | 0.82% | 1.6% |
| 3 | Ofatumumab | Kesimpta | Relapsing multiple sclerosis | 0.47% | 5.0% |
| 4 | Efgartigimod alfa-fcab | Vyvgart | Generalized myasthenia gravis | 0.46% | 0.7% |
| 5 | Efgartigimod alfa-hyaluronidase-qvfc | Vyvgart Hytrulo | Generalized myasthenia gravis (subcutaneous formulation) | 0.25% | 0.7% |
| 6 | Natalizumab | Tysabri (not including Tyruko) | Relapsing multiple sclerosis, Crohn’s disease | 0.22% | 4.0% |
| 7 | Rimegepant sulfate | Nurtec ODT | Acute and preventive treatment of migraine | 0.20% | 3.0% |
| 8 | Eptinezumab-jjmr | Vyepti | Migraine prevention | 0.15% | 6.6% |
| 9 | Ubrogepant | Ubrelvy | Acute treatment of migraine | 0.14% | 5.0% |
| 10 | Cariprazine HCl | Vraylar | Schizophrenia, bipolar I disorder, adjunctive for major depressive disorder | 0.13% | 5.0% |
*Portion of spend for the NDCs making up the top 85% of Vizient pharmacy program participant spend
Pipeline: Anticipated high-impact approvals
| Drug Supplier |
Route | MOA | Indication(s) | Anticipated approval date |
|---|---|---|---|---|
| Tolebrutinib Sanofi |
Oral | Bruton’s tyrosine kinase inhibitor | Multiple sclerosis | 12/28/2025 |
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