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GLP-1 Update: Coverage Expands as Costs Surge – Strategic Management Becomes Essential

by Rx Insights

The GLP-1 landscape continues to evolve rapidly, with new data revealing both expanding employer coverage and intensifying financial pressures. As we’ve highlighted in our ongoing GLP-1 series, understanding these trends, and implementing proactive management strategies, has never been more crucial for plan sponsors.

THE CURRENT MARKET REALITY

Recent data reveals a dramatic shift: 36% of employers now provide GLP-1 coverage for both weight loss and diabetes (1). While this reflects growing recognition of these medications’ value, it comes with serious cost implications. The use of GLP-1 drugs for weight loss currently represents 10.5% of total claims, and 27% of employers report GLP-1 drugs account for more than 15% of their annual drug spend (1). With oral formulations approaching FDA approval, the trend is accelerating.

HOW EMPLOYERS ARE RESPONDING

Faced with these unprecedented cost pressures, more than three-quarters of employers now employ cost-control mechanisms (1), including:

  • Prior authorization requirements (96% of employers using utilization management)
  • Strict eligibility criteria focusing on clinical severity (68% of employers)
  • BMI thresholds and comorbidity requirements (88% require minimum BMI; 60% require obesity plus chronic conditions)

BENECARD’S COMPREHENSIVE GLP-1 SOLUTIONS 

Benecard has developed targeted benefit design features to help reduce the rising costs associated with brand-name GLP-1 drugs prescribed for weight loss while ensuring appropriate clinical care:

  • Clinical Severity Targeting: Limiting weight loss coverage to patients who are qualified as having clinically severe obesity (BMI ≥40 or BMI ≥35 with comorbidities) who face the highest medical cost risks.
  • Defined Treatment Length: Limiting all current, future, and any combination of oral and non-oral weight loss GLP-1 drugs to twelve fills each at a 30-day supply for a lifetime maximum per member.
  • Proactive Market Positioning: Excluding coverage for upcoming oral GLP-1 tablets approved for weight loss and/or for diabetes treatment.
  • Centralized Management: Requiring all brand-name injectable GLP-1s to be filled through Benecard Central Fill (BCF) for enhanced clinical oversight, improved cost control, and access to manufacturer copay assistance programs. 

PREPARING FOR CONTINUED EVOLUTION

Plan sponsors implementing structured GLP-1 management today position themselves for long-term sustainability as this market continues to expand. Our fixed-rate Rx benefit solution provides the predictability you need while our innovative benefit designs help control utilization without compromising quality care.

Ready to discuss how these strategies can work for your clients?

Contact us today at (800) 734-9528 or talktous@benecard.com to explore customized GLP-1 management solutions.

1740504225098

The Oral GLP-1 Race: Medical Breakthroughs Meet Financial Reality

by Rx Insights

The weight loss drug market is evolving rapidly as pharmaceutical companies advance their clinical trials for both oral and non-oral GLP-1 formulations. As Biopharmadive recently noted in an article, “The obesity drug race is far from over, with a plethora of companies vying for a piece of what’s expected to become a huge market in the years ahead. Analysts project that “incretin” drugs, like Novo’s Wegovy and Lilly’s Zepbound, could top more than $100 billion in yearly sales by 2030.” 

While these emerging treatments promise expanded therapeutic benefits for obesity-related conditions as well as improved efficiency in weight loss, they also pose challenges for employer-sponsored prescription plans already experiencing unprecedented utilization and cost increases from GLP-1s.  

Emerging Treatments in Clinical Trials 

These pharmaceutical companies are conducting extensive clinical trials for both oral and non-oral GLP-1 drugs, with each potential treatment still awaiting FDA approval: 

  • Novo Nordisk’s experimental oral drug, amycretin, currently in Phase 3 trials, has shown promise beyond weight loss. By targeting both GLP-1 and amylin receptors, it may offer additional benefits for cardiovascular health and metabolic disorders associated with obesity1.  
  • Eli Lilly’s orforglipron, advancing through Phase 3 trials, demonstrates potential benefits for obesity-related complications including fatty liver disease and sleep apnea2.  
  • Amgen’s MariTide (maridebart cafraglutide), in late-stage clinical trials, is being studied for potential impacts on obesity-related inflammation and metabolic syndrome, with a unique monthly dosing approach3.  
  • Other pharmaceutical companies, including Roche and emerging biotech firms, are conducting trials focusing on broader therapeutic applications for obesity-related conditions while improving tolerability4.  

The Implications for Plan Sponsors 

As these medications progress through clinical trials toward potential FDA approval, many current injectable users may transition to oral versions, while the improved accessibility could drive new patient adoption. This shift will likely intensify the financial pressure on prescription benefit plans. 

In response to these market dynamics, Benecard continues to develop innovative solutions to help manage rising costs of GLP-1 drugs while ensuring appropriate care. Our comprehensive approach includes specialized plan design features which were previously addressed in our three-part bulletin series “decoding the rising Rx trends.” 

Contact us to explore strategies for managing GLP-1 medication expenses while supporting employee health outcomes. 

Sources: 

“The Race for Oral Obesity Drugs: Multiple Phase 3 Trials Vying for Next-Gen Status,” Fierce Pharma. 

“GLP-1 Market Heats Up as Companies Vie for Next-Gen Obesity Drugs,” Outsourcing-Pharma. 

“Why Amgen’s MariTide Could Rival Eli Lilly and Novo Nordisk’s Obesity Drugs,” Business Today. 

“Four Oral GLP-1 Products in Phase III Trials as Race Intensifies,” Clinical Trials Arena. 

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Successfully Managing Rising Rx Costs Starts with Accurate Trends

by Rx Insights

In today’s market if you’re seeing prescription drug trend estimates in the single digits, you should know: those numbers don’t reflect reality. Some trend calculations may focus solely on manufacturer drug price inflation and therefore dramatically understate actual or true prescription benefit trends. To accurately project trends, additional critical factors must be considered:

  • Utilization Patterns – Prescription volume increases yearly as population age and chronic conditions become more prevalent and members simultaneously shift to newer, costlier alternatives. Medical advancements allow for earlier diagnosis which drives longer treatment duration and higher utilization.
  • Specialty and Non-Specialty Pipeline Impact – New to market drugs typically launch at premium price points as compared to existing products. These treatments often expand the treatable population while commanding unprecedented costs.

The Risk of Underestimating

When these factors are properly weighted, we consistently see trends in the mid to higher teens. When plans understate drug trends, they create severe budget shortfalls. This forces employers to make radical mid-year plan design adjustments or significantly increase contributions or benefit reductions the following year, all while making it increasingly difficult to secure stop-loss coverage in the following year without significant rate increases. 

Looking Ahead

While we can’t control drug prices, we can control how benefits are managed. That’s where Benecard Services is different. Instead of just chasing rebates and managing unit costs, we have aligned financial interests with our clients that focus on getting members the right medications while keeping costs in check. No conflicts of interest ― just patient-centered care that works.

With more specialty and GLP-1 drugs in the pipeline, these trends will only intensify. Contact us today at (800) 734-9528 or talktous@benecard.com to discuss how Benecard is helping employers tackle rising drug trends.

New Jersey state capitol building in Trenton

SHBP-Local Government’s Financial Crisis

by Rx Insights

The NJ State Department of Treasury released a report on May 20th confirming that the State Health Benefits Program for Local Government (SHBP-LG) has become financially unsustainable and needs immediate intervention to survive. The report also states that the School Employee Health Benefits Plan (SEHBP) is on the same trajectory and likely to follow the SHBP-LG’s deterioration.

The Immediate Financial Impact

A potential 26.5% increase could be applied as a combination of a mid-year rate increase in 2025 and/or factored into future renewals. This potential 26.5% increase is a culmination of the 7% premium rate increase required to repay the $120 million dollars still owed on a $258 million dollar loan and based on the SHBP-LG exhausting its claim stabilization reserves (CSR) which calls for an additional 19.5% increase.

This increase would be in addition to normal medical and prescription trends. The State’s consulting firm, Aon, projects prescription trends of 18% to 23% for 2026, with medical trends estimated at 8% to 10% based on current SHBP-LG data.  

What This Means for Plan Sponsors in the SHBP-LG

According to the Department of Treasury, immediate action is necessary for the SHBP-LG to survive. These actions require significant rate increases, forced plan design changes, and/or legislative actions. Plan sponsors should begin evaluating alternatives now to avoid compounding rate increases in 2025 and 2026 as well as potential plan design changes.  

Plan sponsors and their brokers should explore private carriers who can offer full risk protection and/or who can offer access to trusts or group purchasing organizations, which provide for greater stability by spreading the risk through such arrangements. While such quotes will likely show double-digit increases, private carriers do not carry the same financial burden as the SHBP does (i.e., debt burden and CSR requirement), which represents a considerable financial reduction for groups who transition sooner rather than later.

NEXT STEPS

Plan sponsors in the SHBP should obtain their most recent claim experience and census as soon as possible which will allow private carriers to provide the most accurate quotes.   If you are currently contracted with a broker, have them contact Benecard’s Vice President of Sales, Richard Van Noord, at (609) 651-5412 or Richard.VanNoord@benecard.com. If you do not have a broker, you can contact Richard directly to explore available solutions.

ATTRUBY™

by NewsUncategorized

FDA Approves Attruby to Reduce Cardiovascular Death and Cardiovascular-Related Hospitalization in Patients with ATTR-CM

BridgeBio Pharma, Inc. has announced that the U.S. Food and Drug Administration (FDA) approved Attruby™ (acoramidis), for the treatment of adults with cardiomyopathy of wild-type or variant transthyretin-mediated amyloidosis (ATTR-CM) to reduce cardiovascular death and cardiovascular-related hospitalization.

The FDA approval is based on positive results seen in the ATTRibute-CM Phase 3 study, where Attruby significantly reduced death and cardiovascular-related hospitalization, and improved quality of life.

  • Attruby is the first and only approved product with a label specifying near-complete stabilization of TTR. It mimics a naturally occurring “rescue mutation” of the TTR gene that targets the root cause of ATTR-CM.
  • Attruby has been shown to preserve the native function of TTR as a transport protein of thyroxine and vitamin A and to demonstrate benefit on cardiovascular outcomes.

Source: BridgeBio Pharma, Inc.

Read more…

ZIIHERA®

by NewsUncategorized

FDA Grants Accelerated Approval to Ziihera for the Treatment of HER2-Positive Biliary Tract Cancer

Jazz Pharmaceuticals plc has announced the U.S. Food and Drug Administration (FDA) accelerated approval of Ziihera® (zanidatamab-hrii) 50mg/mL for injection for intravenous use for the treatment of adults with previously treated, unresectable or metastatic HER2-positive (IHC 3+) biliary tract cancer (BTC), as detected by an FDA-approved test. Ziihera was approved under accelerated approval based on a 52% objective response rate (ORR) and a median duration of response (DOR) of 14.9 months as determined by independent central review (ICR).

  • Continued approval for this indication may be contingent upon verification and description of
    clinical benefit in a confirmatory trial.
  • Biliary Tract Cancer, including gallbladder cancer and intrahepatic and extrahepatic
    cholangiocarcinoma, account for <1% of all adult cancers globally and are often associated with a
    poor prognosis.

Source: Jazz Pharmaceuticals plc

DANZITEN

by NewsUncategorized

FDA Approves Danziten Tablets, the First and Only Nilotinib with No Mealtime Restrictions

Azurity Pharmaceuticals has announced that the U.S. Food and Drug Administration (FDA) has approved Danziten. This is the first and only nilotinib with no mealtime restrictions indicated for adult patients with newly diagnosed Philadelphia chromosome positive chronic myeloid leukemia (Ph+CML) in chronic phase, and in adult patients with chronic phase (CP), and acute phase (AP) resistant or intolerant to prior therapy that included imatinib.

  • Tasigna® has established efficacy in adults with newly diagnosed Ph+ CML-CP and resistant or
    intolerant Ph+ CML-CP and CML-AP; however, Tasigna has variable bioavailability that considerably
    increases when taken with food.
  • Danziten offers a new nilotinib treatment option with the equivalent efficacy to Tasigna, but
    without the fasting requirements of Tasigna.

Source: Azurity Pharmaceuticals, Inc.

Read more…

Daybue™

by NewsUncategorized

FDA Approves Daybue (trofinetide) for the Treatment of Rett Syndrome

Acadia Pharmaceuticals Inc. announced that the U.S. Food and Drug Administration (FDA) has approved Daybue (trofinetide) for the treatment of Rett syndrome in adult and pediatric patients two years of age and older. Daybue is the first and only drug approved for the treatment of Rett syndrome.

Rett syndrome is a complex, rare, neurodevelopmental disorder typically caused by a genetic mutation on the MECP2 gene. It is characterized by a period of normal development until six to 18 months of age, followed by significant developmental regression with loss of acquired communication skills and purposeful hand use. Symptoms of Rett syndrome may also include development of hand stereotypies, such as hand wringing and clapping, and gait abnormalities. Rett syndrome is believed to affect 6,000 to 9,000 patients in the U.S.,with a diagnosed population of approximately 4,500 U.S. patients. Daybue is not recommended for patients with moderate or severe renal impairment.

Daybue™ is expected to be available in the U.S. by the end of April, 2023.

Read more…

Zavzpret

by Uncategorized

Pfizer Inc. has announced the U.S. Food and Drug Administration (FDA) has approved Zavzpret (zavegepant), the first and only calcitonin gene-related peptide (CGRP) receptor antagonist nasal spray for the acute treatment of migraine with or without aura in adults. There are several other CGRP antagonists currently on the market — some for acute treatment of migraine, others for migraine prevention, and some can be used for both. (i.e. injectables: ajovy, aimovig, emgality, vyepti oral: qulipta, ubrelvy, and nurtec).

In its pivotal Phase 3 study, Zavzpret was statistically superior to placebo on the co-primary endpoints of pain freedom and freedom from most bothersome symptom at two hours post-dose. The pivotal study also demonstrated pain relief as early as 15 minutes in a prespecified secondary endpoint versus placebo.

The FDA approval is based on two pivotal randomized, double-blind, placebo-controlled studies that established the efficacy, tolerability and safety profiles of Zavzpret for the acute treatment of migraine. In these studies, Zavzpret was statistically superior to placebo on the co-primary endpoints of pain freedom (defined as a reduction of moderate or severe headache pain to no headache pain) and freedom from most bothersome symptom at two hours post-dose (defined as the absence of the selfidentified most bothersome symptom).

Zavzpret is contraindicated in patients with a history of hypersensitivity to zavegepant or to any of its components. Hypersensitivity reactions, including facial swelling and urticaria, have occurred with Zavzpret in clinical studies.

Zavzpret is anticipated to be available in pharmacies in July 2023.

Read more…

Researchers announce highly accurate blood test for Alzheimer’s Disease

by Uncategorized

A team of researchers from Rowan-Virtua School of Osteopathic Medicine (RowanVirtua SOM) and Durin Technologies, Inc., have announced the results of a newly-designed blood test that can detect the presence of Alzheimer’s disease-related pathology up to 10 years before symptoms arise with a nearly 97 percent accuracy rate. Their findings appear online ahead of press in the Journal of Alzheimer’s Disease.

The study involved 328 blood samples with the goal of determining if a test that monitors a small number of a patient’s autoantibodies can detect Alzheimer’s disease (AD)-related pathology at presymptomatic, prodromal (i.e., mild cognitive impairment), and mild-moderate stages of the disease.

The research team showed that their test, using just eight autoantibody biomarkers, could accurately identify the presence of Alzheimer’s disease pathology across the disease’s progression, including among those originally determined to have no trace of the disease.

For a number of reasons, the test has significant potential to impact effective treatments for Alzheimer’s disease. The test is minimally invasive and inexpensive, it can diagnose or predict clinical decline in asymptomatic individuals, and it can monitor a patient’s progress while under treatment, making it ideal for use in clinical trials and in frontline and community primary care settings, including those in rural and economically disadvantaged regions.

The researchers noted that the use of autoantibodies as blood-based biomarkers is particularly exciting because it enables development of a platform technology for early detection of multiple diseases.

Read more…