In the past year, medicines and therapeutics have made big strides—from first-in-class treatments to therapeutic milestones and a once-unthinkable “functional cure.”

That latter distinction belongs to Casgevy, the first CRISPR-based therapeutic approved by the Food and Drug Administration—which came to fruition less than a decade after the gene-editing technology was first developed. Developed by Vertex Pharmaceuticals, in partnership with CRISPR Therapeutics, Casgevy is a treatment for sickle cell disease that could benefit some 16,000 patients. But even as the Biden administration negotiates discounts for state Medicaid plans, the drug’s uptake could be limited by its $2.2 million price tag.

High list prices have become a hallmark of the most advanced therapies. Take the latest drug meant to help slow the progression Alzheimer’s disease. The therapy, Leqembi, offers unprecedented hope for the 6.7 million older Americans living with its effects. Developed by Eisai with partner Biogen and granted FDA full approval in July 2023, the infused therapy is the first treatment to clearly slow cognitive decline and reduce amyloid plaques in the brain, whose buildup is a key driver of the disease. About 1 million Alzheimer’s patients in the U.S. could qualify for the treatment, and the drug’s annual price tag of $26,500 along with frequent scans and monitoring could cost taxpayers $82,500 per patient per year, according to estimates from the nonprofit Institute for Clinical and Economic Review. Six months after approval, between 2,000 and 3,000 people in the U.S. were receiving the therapy.

But without a doubt, the top drug-cost story of 2023 was about category of blockbuster diabetes anti-obesity drugs known scientifically as GLP-1 receptor agonists. They’re better known by their brand names Ozempic, Wegovy, Mounjaro, and Zepbound. Developed and manufactured by longtime rivals Novo Nordisk and Eli Lilly, these drugs have rewritten the rules of weight loss and caused a profound shift in the pharma landscape.