Payers are adjusting their pharmacy benefit strategies as they address strong demand – and high prices – for GLP-1 drugs for weight loss.
"As drug costs climb, payers are under pressure to reevaluate benefit design and cost-management strategies," said Morgan Lee, vice president of research and marketing at Pharmaceutical Strategies Group. "The debate around GLP-1 coverage is a prime example of the balancing act benefits leaders face as they navigate skyrocketing demand, affordability concerns and uncertainty around long-term patient outcomes."
The company's 2026 Trends in Drug Benefit Design Report found that nine in 10 respondents were moderately or very concerned about the affordability of GLP-1 therapies for the plan. Nearly half of payers who do not currently cover GLP-1s for obesity would not do so at any price.
Additionally, high discontinuation rates now play a major role in coverage decisions. Nearly two-thirds of patients without type 2 diabetes who take GLP-1s discontinue treatment within one year. Seventy-two percent of respondents indicated that discontinuation rates and weight regain were at least moderately influential in their GLP-1 coverage decisions.
With the pharmacy benefit manager market expanding and increasing scrutiny of vertically integrated models, payers increasingly are exploring partially or fully unbundling PBM services to control costs and gain greater transparency. Almost two-thirds of health plans and approximately half of employers would pursue a partially or fully unbundled PBM model if conducting a procurement today, while overall perceived value of these arrangements increased year-over-year.
The rapid growth of direct-to-consumer pharmacy offerings is raising new questions for payers around member engagement and pharmacy benefit strategies. Awareness of established programs such as GoodRx is high (91%) among respondents. However, familiarity with newer offerings such as TrumpRx (66%) and Cost Plus Drugs (64%) is lower. Approximately half of respondents said they currently use strategies related to discount card or direct-to-consumer programs, and a similar share engages with members about these offerings in some way.
In response to rising drug costs and dynamic pricing models, payers are considering changes to their cost-sharing arrangements and exploring alternative pricing models. Seven in 10 payers are considering changes to their cost-sharing arrangements. Higher copays, coinsurance and deductibles are among the most frequently considered changes. Pricing arrangements are drawing increased attention. Nine percent of payers report use of a cost-plus pricing arrangement and 11% use per-member-per-month pricing guarantee.
"This report highlights the difficult tradeoffs employers face as they work to balance affordability, access and quality," said Snezana Mahon, PharmD, president of Transcarent, which sponsored the report. "The findings point to a growing focus on transparency, accountability and the importance of having pharmacy at the center of an employer's benefits strategy for better health and care."
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