Posts in category: 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.

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. 

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.