Costs of GLP-1 drugs for weight loss and diabetes are escalating rapidly. Although cost-containment strategies have been used in recent years, GLP-1s still account for a large portion of the increase in pharmacy spending. They now make up 21% of the pharmacy benefit spend and 4–5% of medical and pharmacy spend together.
Although GLP-1 drugs for diabetes are covered by almost every employer-sponsored health plan, GLP-1 drugs for weight loss aren't covered by all employers. In our 2024 Best Practices in Healthcare Survey, 52% of respondents said that they provided coverage for GLP-1 medications for obesity.
Given this exponential trend, many of you are finalizing your coverage decisions and strategy for 2026. You may be reconsidering coverage for weight loss and are exploring alternative benefit design options including:
- Limiting eligibility to a higher BMI: This change can lead to fewer rebates, reducing expected cost savings.
- Using an obesity or cardiometabolic vendor to prescribe and manage drugs: Use current vendors to manage GLPs or request proposals. More data is needed as to whether vendors can provide meaningful change and reduction of costs.
- Subsidizing a portion of drug costs through vendors like Rx Save Card: Through an integrated health reimbursement account, you can designate a set dollar amount for coverage, which provides predictability.
- Promoting direct-to-consumer (DTC) channels like Lilly Direct and NovoCare: The DTC price for these medications is lower than the net employer price after rebates and discounts. If you decide to remove coverage, you can let your members know about the DTC channel options.
Making decisions is more difficult because of changing adherence, dealing with drug shortages and the uncertainty about whether to stop taking the drugs.
Many of you may feel limited in your ability to manage GLPs effectively because most of these options will result in a loss of rebates or adjustments to the rebate guarantee offered by the pharmacy benefit manager. We're listening to your pain points and working on creative ways to address GLP utilization beyond access.
Implications to consider
- Utilization will continue to rise. A robust pipeline of new GLP-1 drugs later this year and in 2026 will bring more competition with the potential to drive lower unit costs.
- Government price negotiations for Medicare Part D plans could also put downward pressure on GLP-1 drugs in the commercial market.
- The drugs will likely gain other uses this year including metabolic dysfunction associated steatohepatitis, heart failure and peripheral artery disease, which will also contribute to more utilization.
