GLP-1s have become one of the clearest examples of how quickly pharmacy strategy can fall behind the market.
What started as a type 2 diabetes and weight management conversation is now expanding into a broader coverage decision for plan sponsors. New indications, rising utilization and direct-to-consumer cash pricing are changing the GLP-1 environment faster than most plans were built to respond.
In this episode of On Point with Navion, Brian Shonat walks through the GLP-1 market shifts plan sponsors need to consider ahead of 1/1 renewals.
What’s Driving GLP-1 Spend and Coverage Pressure
GLP-1 spend continues to rise because the category itself keeps expanding. Approved uses now reach into areas such as cardiovascular risk reduction, obstructive sleep apnea, chronic kidney disease and MASH, with additional research underway in areas such as osteoarthritis, substance use disorder, hypertension and more.
For plan sponsors, that creates pressure from several directions:
- More eligible members: Every new indication can create another population of members who may qualify for treatment.
- Higher utilization risk: A group’s current GLP-1 spend may look manageable today, while the long-term trajectory is still moving up.
- New cash-pay options outside the PBM: Direct-to-consumer pricing may give members lower-cost options outside the PBM, but those fills may not flow through the benefit or apply to accumulators.
- A complicated ROI picture: GLP-1s may help slow medical cost growth, but pharmacy spend can still outpace those savings—especially when employees may only stay on the plan for a few years.
- More pressure from employees: Broad coverage can be expensive, but restrictive coverage may become harder to defend as employees pay closer attention to their benefits.
That puts employers in a difficult middle ground. The right answer depends on the group’s population, budget, workforce strategy and tolerance for pharmacy cost risk.
What Employers Should Review Before GLP-1 Decisions Lock In
Before GLP-1 coverage decisions are finalized, plan sponsors need a clear picture of what’s already happening in their own data.
That starts with utilization and spend trend over the past several years, not just the current plan year. Groups should understand who is new to the GLP-1 category, who is new to the plan and where utilization could move if coverage expands beyond type 2 diabetes.
They should also review how the PBM is managing access. Prior authorization criteria and utilization management rules can vary significantly, and those rules should match the group’s actual coverage goals.
Some groups may choose broader coverage. Others may decide to stay narrower for now. Either way, the decision should be backed by data, tied to a clear strategy and supported by the right PBM management criteria.
There’s no one-size-fits-all answer for GLP-1 coverage, but there is a clear need for plan sponsors to dig into their data, define their coverage position and make sure their PBM strategy supports that decision.
Do you need a clearer read on how GLP-1 utilization could affect your pharmacy benefit? Navion combines claims analysis, clinical insight and cost-containment expertise to help plan sponsors and their partners understand current spend, evaluate future risk and make more confident Rx decisions. Let’s talk!
