2026 Georgia Society for Healthcare Human Resources Administration (GSHHRA) Annual Conference-GHA

GHA_Navigating the Rx Landscape

Pdf Summary

Callie Roberson (Gallagher Pharmacy Practice) outlines how GLP‑1 drugs are reshaping employer pharmacy benefits and why PBM strategy must evolve. The PBM market is increasingly competitive (60+ PBMs), dominated by the “Big Three” (CVS, Express Scripts, Optum) with 80%+ share, while middle-tier and “disruptor” PBMs compete with more employer-friendly and transparent models but less scale and potential integration challenges.<br /><br />Key pharmacy trend drivers include GLP‑1s, specialty drugs, biosimilars, transparency, and employers’ fiduciary responsibilities. GLP‑1 demand is accelerating due to expanding indications (diabetes and weight loss), heavy direct-to-consumer marketing, and a robust pipeline—especially new oral/tablet formulations expected around 2026 that reduce initiation barriers and may increase persistence. Costs remain high (about $10,500–$12,500 per patient per year), with typical median therapy duration around six months and discontinuation rates up to 40% within a year. While some analyses show GLP‑1 users may have lower medical trend (e.g., fewer ER visits and hospitalizations), the presentation concludes current drug costs generally outweigh medical savings, making demand management critical.<br /><br />The talk highlights emerging DTC/DTE channels (e.g., TrumpRx as a search/redirect portal) and notes the Feb. 4, 2026 FTC–Express Scripts settlement, which emphasizes net-price-based member cost sharing, bans spread pricing in certain contexts, limits high‑WAC favoritism, expands DTC access counting toward deductibles/MOOP, and increases transaction-level transparency.<br /><br />Employers are advised to set clear coverage rules, communicate consistently, review plan options early, and monitor utilization/spend. Weight-loss GLP‑1 coverage strategies range from exclusion to PBM “carve-in,” third-party “carve-out,” HRAs/capped benefits, and mandatory weight management programs.<br /><br />Finally, Gallagher promotes simpler contracting approaches (including PMPM/net cost guarantees), stronger auditing and oversight, and coalition offerings to improve predictability, transparency, and total cost of care sustainability.

Keywords

GLP-1 drugs

employer pharmacy benefits

PBM strategy

Big Three PBMs (CVS Express Scripts Optum)

PBM transparency models

specialty drug trend

biosimilars adoption

direct-to-consumer pharmacy channels

FTC–Express Scripts settlement 2026

GLP-1 weight-loss coverage strategies