2026 Enlyte Trends Series

Drug Trends Analysis

The State of Workers' Comp and Auto Pharmacy

Nikki Wilson, Pharm.D./MBA, Senior Director, Clinical Pharmacy Services

As a member of Enlyte's clinical team, I'm excited to share our annual drug trends analysis. Each year we look at our clients' experiences to uncover the most accurate view of the pharmacy trends we're seeing in workers' compensation and auto. Our 2026 series provides an overall view of both in- and out-of-network prescriptions from 2025. Be sure to check out the snapshot reports, short highlight videos, our total view webinar, and more as the series unfolds throughout the year.

›Topical Medication Trends

› Combined In-Network and Out-of-Network Trends

› Retail and Mail Order Prescriptions

› The Pharmacy Blind Spot

› Fewer Prescriptions, Bigger Price Tags

› Opportunist Categories

› Specialty and Injectables

› Opioid Trends

› Total View Webinar Registration

Topical Medication Trends

Building on our broader 2025 Drug Trends analysis, this section narrows the lens to the topical therapeutic class—a category that continues to command outsized attention due to its disproportionate cost impact relative to prescription volume. Examining utilization and spend across both in-network and out-of-network channels, this analysis captures the full scope of topical prescribing patterns that extend beyond traditional pharmacy benefit management reporting. While in-network data reflects the effectiveness of integrated clinical controls and formulary management, out-of-network topical trends expose significant pricing anomalies, opportunistic product proliferation, and jurisdictional factors that complicate cost containment. Together, these perspectives reveal where topical spend is concentrated, what's driving cost inflation, and where targeted interventions can promote clinically-appropriate prescribing while delivering meaningful savings.

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Hey, everybody. It is Nikki Wilson, senior director of clinical pharmacy services at Enlyte, and I'm back to talk to you more about what we found in our drug trends analysis looking at data from 2025 compared to 2024. This last installment, we were focused on what's going on with the topicals in our space. Big area of focus for today's pharmacy benefits managers and those who want to improve their pharmacy program. So interestingly, we looked at in and out of network data, and one thing I want to talk about is some of the top topicals, that's fun, some of the top topicals that are driving the costs that are coming through that particular therapeutic category in each network space. So if we look first at the in network topical space, we saw methyl salicylate twenty five cream, methyl salicylate ten percent patch, and lidocaine four percent patch driving the majority of spend through that particular channel. All of those particular products are available as generics, many of them are also available over the counter, but there are a few outlier NDCs or National Drug Code specific products that we see driving spend in those areas. And actually Juris becomes really important when we start to drill down into where these cost drivers are coming from, and a lot of these are coming through jurists like New York that have a formulary setup to include these types of medications, but we're seeing some particular dispensers in that space that are contracted network pharmacies for continuously reaching for those high cost versions of drugs that are generically and clinically equivalently available in lower cost options that are out there. So let's talk a little bit about each one. Methylsilicylate twenty five percent cream was the top at 14.4% of the topical spend in the in network space. It is available as an over the counter product as well. Volume in the class is about 5% of all the scripts that we saw come through in those retail and mail order pharmacies. The average average wholesale price per script for that product was close to a thousand dollars, which is extremely outsized when you consider the alternatives that are available. Many of the over the counter ingredients contain additional counter irritants and other certain aesthetics like camphor and menthol that may add to the products efficacy when you're looking at an over the counter product but they are a fraction of the cost. So if you're looking at methyl salicylate twenty five percent cream, there are many products available over the counter that are including those same active ingredients, same dosage form often, so cream to cream, same strength or close to it. Most of the over counter products have 30% methyl salicylate but you can get them for about $8 for a 114 gram tube which is a huge cost difference when you're looking at almost a thousand dollars for another type. Another big one in that class was methyl salicylate 10% patch, similar story there. Average price was even more on the cost driver NDCs that we saw coming through as the number two in the class for driving spend, $2,759 average AWP per script for that particular product. When there's an over the counter 10% menthol version out there that's about a dollar per patch or less, you so could be looking at $30 for a thirty day supply perhaps or maybe if you're getting $60.60 dollars but significantly less than the nearly $3,000 options that we're seeing come through today. And the last one is lidocaine 4%. That's also available over the counter. The over the counter 4% patch is also around a dollar a patch which blows out of the water. The pricing that we're seeing on some of those branded private label topical products that are coming through as lidocaine 4% like Xylitol which runs about $800 average package size 15 versus the again less than a dollar around a dollar per patch for the equivalent versions that are available over the counter. Those are primarily coming through New York all those ingredients are listed as New York onboard formulary agents so methyl salicylate and lidocaine are both on there so this prescribing practice that we're seeing that's really driving cost and that in network space is choosing the highest cost versions of some of those agents or those that don't have a direct equivalence that can bypass that par process. So for example lidocaine let's look at that and look at what the New York non acute pain medical treatment guidelines say topical lidocaine is only indicated when there is documentation of a diagnosis of neuropathic pain. The trial period recommended is no greater than four weeks for that topical lidocaine and it can be considered with the need for documentation for functional gains as criteria for additional use. So per the New York State Workers Comp Board they also have language in there that promotes the least expensive clinically equivalent generic version should be prescribed. So then again it always talks about that documentation of efficacy with examples of improved or continued maintenance of function etc. As being a requirement. There's some checks and balances that payers can use understanding your pharmacy spend where it is and what some of your regulatory controls are as far as managing those become very important. On the flip side when you're talking about out of network we're seeing a different mix of topicals that are coming through that particular channel. Two of them are prescription only products, had two diclofenac products that came through, these are big with physician dispenser billers and then another thing that we're seeing a lot of is mail order pharmacies where physician dispensing regulations have gotten a little tighter. We're starting to see partnerships between clinics and facilities with particular mailer pharmacies who are marketing directly to the workers comp or injured population, personal injury as well just to get them home delivery of their meds which sounds like a great setup. However, those are prescriptions that are often bypassing our clinical and cost controls that are in place through a network environment. So something to pay particular attention to, we called out in the last installment our top three jurists by Spend for out of network topicals. They were Florida, Pennsylvania, and Illinois and all three of those have some allowance for physician dispensing. In Pennsylvania where there's a little bit more of a limitation on that type of dispensing we see a large percentage of that cost and spend for topicals coming through mail order pharmacy partnerships like I just described. So it depends on what's allowed regulatory wise, the reconsideration pathways in those states are fairly strong as well. So we hear some noise from our customers about battling these these high priced products and looking for opportunities to sort of guide towards an alternative. So let's just talk about one of them to give an example. Here we'll talk about Diclofenac three percent gel. The brand name for that particular product is Solaraze and there are a number of different strengths of diclofenac available in different formulations. One of our preferred products on our formulary at Enlight is diclofenac one percent gel. It is indicated for osteoarthritis and aches and pains of joints especially elbow, wrist, hand joints, upper extremities, minor joints. It is available over the counter and generically so it's a very cost effective option for topical treatment than Clofinet. The three percent gel we see often prescribed out of network costs on average $1,500 per script when it's coming through that channel. It does have a generic available but the big sticker here is the three percent gel is only FDA approved for a topical condition that you wouldn't see as part of an injury. It's actinic keratosis which is not injury related in any way shape or form so it's one of those where it's being used off label and it's a huge cost driver when the over the counter agent is significantly less. So really what the best thing, that I can give you as far as advice is to try to control for some of these topicals that we're really seeing drive spend and lead, category spend for pharmacy programs both in and out of network depending on what you're looking at. It helps to know where where is your cost coming from? Is it more of an in network issue? Are you seeing large spend out of network? What makes up that drug mix? What jurists? If you're looking at a workers comp program and what levers can you apply from a clinical and regulatory perspective to drive meaningful reductions in cost while maintaining appropriate patient care? That is all I have for today so hope you gain some insight from that and reach out to your pharmacy benefits manager today to see if you can get some closer look into some of those cost drivers in your own program. Thanks for joining me.

Combined In-Network and Out-of-Network Trends

This analysis provides a comprehensive examination of prescription utilization across both in-network and out-of-network channels including retail pharmacies, mail-order services, and paper-based medical bill submissions. This dual-lens approach captures the full prescription landscape that extends beyond traditional pharmacy benefit management reporting, revealing critical cost and utilization patterns across all jurisdictions. While in-network channels demonstrate the real-time effectiveness of integrated clinical controls and cost management strategies, out-of-network data, often representing acute treatment episodes captured through medical bill review, exposes significant cost management opportunities and pricing anomalies. Together, these perspectives illuminate where pharmacy dollars are spent, how prescriptions are managed, and where targeted interventions can drive the greatest impact on both clinical outcomes and costs.

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Hey, it's Nikki Wilson, Senior Director of Clinical Pharmacy Services at Enlyte, and I'm here to talk about some of the out of network trends that are driving different data in the set that we just examined, looking at book of business clients where we have both a bundled program for PBM or pharmacy management along with Smart Advisor, our bill review solution. So it's seeing everything that's coming through the retail and mail order spaces that we can manage up front, as well as some of those medical bills that are coming in with prescriptions on them that we're able to manage retrospectively on the back end. So some things that really stood out in the data for the out of network space in particular were driven by, in part, Juris rules. And I'm also going to highlight some unique things that we saw in the drug mix itself. None of this will come as a surprise to many who've been in this space for a long time, but out of network presents its own unique set of challenges that require a different approach, different strategies to try to really get in front of the issue because we're dealing with medications that have been already dispensed. They're post dispensed, and now a biller is coming to the payer looking for payment for those particular items. So one thing that really stood out is we did an analysis to see what the top states by billed amount were within the dataset, And there were five that bubbled to the top. They were in descending order: Florida, New York, Pennsylvania, Tennessee, and Illinois. And I'm just going talk about the top two to sort of point out some of the things that might be impacting that leading spend and that leading driver. Florida was the number one by billed amount in those top states, and it had a fairly even split of what part of the billing was coming in network versus out of network. Forty one percent of spend was in network, fifty nine percent of spend was out of network. The average script cost was also higher out of network, which that's pretty true for a lot of our out of network bills that come through with prescriptions on them. Partly that's due to things like physician dispensing being allowed in the state of Florida. Dispensers are able to bill and dispense high dollar products. Often we see a lot of opportunistically priced products like three percent Diclofenac coming through that space or boutique dosing of cyclobenzaprine, for example, coming through that space. It's really difficult to manage those with upfront clinical controls when they're already in the hands of the patient, so they need a different approach to management. On the flip side, the number two by billed amount in this data set was New York. And New York is a little different animal. New York actually allows for direction of care for so you can enforce a pharmacy network as a workers' comp payer, less applicable to auto space, but when we're looking at workers' comp regulations, that is a big driver of what we see in the split for spend. It's about eighty eight percent of the spend is in network in New York, twelve percent out of network. And that really reflects that ability to enforce in network use of a pharmacy. Interestingly, the average cost per script is higher in network for New York. It came in at an average of about two fifty eight dollars per script versus one hundred and sixty four dollars out of network. Not super typical to what we see, but lately we've seen a trend in New York where the formulary allows for certain medications. There's a state based formulary in New York for workers' comp prescriptions where, for example, methyl salicylate is on the formulary. However, we're seeing prescribers prescribing and pharmacies dispensing the highest dollar version of methyl salicylate, and getting reimbursed and paid. So they're maybe dispensing a forty percent oil version of methyl salicylate for three thousand dollars when over the counter versions exist for three dollars a pop. They're not in the oil form, but they're clinically equivalent and have no, proven advantage. So that's one of the things that we're tracking and watching in that state. The other thing I wanted to mention was just the drug mix that we see out of network. One thing that really jumped out to me when we split and compared out of network spend versus in network spend is the top therapeutic classes by build amount, by dollar amount. In out of network, topicals took the lion's share at just over forty one percent of total spend for that year in the out of network space. When you compare that to the in network slice of the pie, the top therapeutic class by spend there was opioids and it held a fourteen percent share of that spend. So you can see there's a disproportionate weight when it comes to the spend that is taken over in the out of network space. So what does this mean for you? There's a lot of different rules, lot of different things going on in the dispensing space that color that picture for out of network spend versus in network. That's just one area to look at, but engage with your compliance team, your internal resources, your PBM to develop a strategy and work with them to monitor and review some of those things with ongoing analytics and different strategies for approach to have the greatest impact. Thanks for joining me.

Retail and Mail Order Prescriptions

Key insights reveal significant shifts in the workers' comp and auto pharmaceutical landscape that impact claim costs and injured employee care. Our analysis of in-network retail and mail order prescription data shows encouraging trends, including decreased overall prescription costs despite rising prices in key therapeutic categories like migraine medications. This comprehensive review examines evolving medication utilization patterns, specialty drug impact, and the continued decline in opioid usage to help stakeholders make informed decisions within their pharmacy programs.

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Hey, it's Nikki Wilson, Doctor of Pharmacy and Senior Director of Clinical Pharmacy Services at Enlyte. So we just published our first release of drug trends, I wanted to dive into a couple of highlights, mainly around the migraine medication trend that we continue to see on the rise. So this report was in network data only across our entire book of business. It was comparing the year twenty twenty five with the year previous, And what we saw continue is that overall cost and utilization by claim across the entire drug category set was down compared with the year previous. However, migraine costs rose by nearly ten percent for cost per script across retail and mailer channels in twenty twenty five. Migraine utilization also rose by nearly ten percent. So that double whammy of more scripts and costlier scripts has led for that to be one of the top trending categories over the last couple of years. So what's behind the trend? Migraine is prevalent. It's the second leading cause of disability worldwide. It's number one if you look at disability in individuals younger than fifty years old, and it affects about forty percent of the population. You probably know somebody that suffers from migraines, or maybe it's you yourself. It's really common. It's in fact the sixth most prevalent disease worldwide. And so knowing that this is a diagnosis many of us carry, now it's time to consider the cause factors. Drug manufacturers realized that there was a need for new and better treatments and developed the first CGRP inhibitors, calcitonin gene related peptide inhibitors, back in May of twenty eighteen. We saw our first FDA approval. Why are these different? How do they work? So they were new in the way that they affected migraine headache complaints. They decreased the level of calcitonin gene related present during a migraine attack, which those levels have been shown to be correlated with the intensity of headache pain and is something that's released when one of those attacks is in place. So we have a number of products on the market. Since they're newer, they're all brand medications and carry a pretty hefty price tag, but there's a number of options for both acute and preventative treatment of migraine today. So in fact, that category, CGRPs, the pricing ranges from about nine seventy dollars to two thousand dollars average wholesale price per script for a one month supply. The average cost that we see associated with those drugs is about twelve hundred dollars per month. And in fact, we saw migraine medication break into that top ten therapeutic classes by Spend in twenty twenty two. And that's just continued to be the case over the last several years. This last year, they were at number six by Spend. The three top three leading meds in that category are all brand oral medications for migraine prevention and treatment. Nurtec ODT with an average wholesale price per script of two thousand and thirty seven dollars Ubrellvi at seventeen ten dollars and Qlipta at fourteen forty six The specialty category also includes four injectable or infusion, IV infusion products that are in the CGRP category. They're on the market for preventative treatment of migraine only, and those are Emgality, Aimovig, and Viupti. And so those are currently driving spend in that category as well, but they're a good option for preventative treatment. I do want to point out there's still a number of other options on the market, many available as generics that are still very tried and true and have good evidence for efficacy. But these newer classes are being reached for more and more by prescribers and patients based on their ability to control migraine frequency and pain. So they, there's something to take a look at. So recommendations for your program, look at the prevalence of migraine medications in your book. Two things I always recommend for this category of meds is confirm you have a true diagnosis of migraine. There's a number of criteria that need to be met in order for it to be considered true migraine and not just a headache. And these drugs are only appropriate for migraine complaints. That criteria can be found in the official disability guidelines, which is unique to the workers' comp space and a number of other resources. And then number two, look at causation, look at work relatedness and ensure that given the prevalence of this disease state, that there is a tie to that work related incident. So that is it for this session. And I'm looking forward to diving into a full view of pharmacy trends in our next release, which we'll look at in and out of network. So I'll see you then.

PHARMACY SOLUTIONS PODCAST

The Pharmacy Blind Spot Created by Opportunistic Products

Nearly 69% of all opportunistic pharmacy spend occurs through out-of-network channels with 11.3% of these scripts driving a staggering 45.5% of cost. In this Enlyte Envision Podcast, Cameron Hannum, Pharm.D., Sr. Clinical Account Pharmacist, examines opportunistic products, high-cost topicals and the out-of-network channels where these costs can be harder to manage. Hear what payers should watch for and how greater visibility across pharmacy activity can help identify emerging cost drivers and support stronger cost management.

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Drug Trends 2026: Nikki Wilson and Cameron Hannum

PHARMACY SOLUTIONS PODCAST

Fewer Prescriptions, Bigger Price Tags

Prescription utilization in workers’ comp continues to decline, but that doesn’t mean drug costs are no longer a concern. In fact, our latest drug trends analysis finds a small number of high-cost prescriptions are creating an outsized impact. In this Enlyte Envision podcast, Brian Allen, vice president of government affairs explores what’s driving these costs, how some providers are exploiting gaps in the system and what states can do to rein in abusive pricing.

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PHARMACY SOLUTIONS WEBINAR

The State of Pharmacy Trends in Workers' Comp and Auto Casualty

Payers continue to face numerous challenges when managing pharmacy care in workers' compensation and auto. While opioids continue to represent a decreasing portion of overall prescriptions and costs, other medications have seen fluctuations with certain classes seeing double-digit cost increases. Opioids, emerging drug classes, varied dispensing channels, and high-impact pharmaceuticals all require new levels of analysis and understanding. Join us as we wrap up this year's drug trends series and hear our experts share more insights on the latest workers' comp and auto drug trends in this total view webinar.

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Each year Enlyte experts analyze drug utilization and spending trends to provide the best insights into pharmacy management. Our annual series reflects the trends our clients experienced including both in- and out-of-network prescriptions as well as additional insights through podcasts, videos, and our on-demand webinar.

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