Among large organizations (500+ employees), 44% cover GLP-1s for obesity. Among the largest (5,000+ employees), the figure has increased from 28% in 2024 to 43% in 2025. "Fiduciary responsibility is becoming more important each day, as employers must demonstrate that coverage decisions reflect true value rather than just headline discounts," notes Friedman in this context.
Coverage decisions now shape how workers view their benefits package. "From the employee's point of view, it's about fairness. Does the employer offer coverage, and is the process impartial? In white-collar industries, GLP-1 coverage is becoming a recruitment tool. For unions and blue-collar workforces, the focus is on equity, making sure low‑wage workers aren't left behind by benefit designs that are easier for higher‑income employees to navigate," explains LaShai Payne, senior vice president, Keenan Pharmacy Services at Gallagher.
Managing cost without cutting access
The clinical case for coverage is getting stronger as GLP-1 indications expand into cardiovascular disease, sleep apnea and substance use disorders.
As these indications broaden, the potential to prevent costly complications like strokes or heart attacks also grows, and with it the opportunity for long-term savings. "The return on investment (ROI) for say diabetes is clear and immediate because the risks are urgent. With obesity, however, the ROI can often take three to five years to manifest," Payne emphasizes, noting that the timeline varies depending on the specific condition.
These longer timelines make it harder to capture returns, especially in high‑turnover roles. Even so, the financial complexity doesn't mean access should be denied. "Coverage is becoming a brand and political signal. The challenge is how to structure programs that provide reasonable access while staying within their budgets," frames Payne in a broader context.
"The decision of covering GLP-1s can't just open the floodgates. There has to be a structured approach: defined eligibility criteria, prior authorization that adds genuine clinical value, wellness programs, and clear expectations for ongoing treatment," Friedman cautions.
Getting the clinical framework right is one part of the solution. The other is making sure the PBM contract actually delivers value.
From black box to glass box
Across the United States, legislators have targeted spread pricing, a model in which some PBMs charge a health plan more for a drug than they reimburse the pharmacy. The Federal Trade Commission (FTC) found that the three largest PBMs collected $1.4 billion this way between 2017 and 2021.1
That business model is now under direct legislative pressure. More than half a dozen states have enacted reforms. Examples include:
Arkansas: Prohibits PBMs from owning pharmacies
Alabama: Requires PBMs to reimburse community pharmacies at Medicaid rates and prohibits patient steering
Iowa: Limits PBMs under-reimbursement, curbs specialty drug labeling and sets a standard dispensing fee
California: Requires pass‑through pricing, where PBMs can only bill plans what they pay pharmacies
While these reforms protect against over-pricing, legislation alone does not guarantee savings. Employers need to verify that their PBM contracts reflect the new rules: explicit pass-through language, capped fees, audit rights and clawback provisions.
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When employers require PBMs to meet all legislative standards and take on full financial risk, the focus shifts to achieving the lowest net cost, not chasing rebates. This approach closes loopholes, drives down costs and delivers real accountability.
Seth Friedman, Pharmacy and Health Plan Services, national practice leader at Gallagher.
How PBMs are adapting
PBMs, however, are finding new ways to protect their margins. Some are increasing administrative fees, others are applying more aggressive formulary controls, pushing patients toward options that generate higher rebates, even when the clinical value is debatable.
"PBMs are creating their own programs with cost caps, limited pharmacy networks and added support, such as lifestyle coaching, to keep GLP-1 medications inside their rebate ecosystem," highlights Payne.
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Transparency from PBMs about pricing and rebates for weight loss drugs is important so organizations can do a proper cost-benefit analysis.
LaShai Payne, senior vice president, Keenan Pharmacy Services at Gallagher.
But this shift only highlights a larger truth: Rebates don't automatically translate into savings for employers. In fact, a high rebate on a high-priced drug can still be more expensive than a lower-priced alternative with a modest rebate.
In other words, dollars returned don't always match dollars spent. And that gap between list price and real value, the space where PBMs have long operated, is exactly what new federal initiatives are aiming to disrupt.
Government as a market maker
In February 2026, the government launched TrumpRx.gov, a portal where patients can buy discounted drugs — including weight‑loss medicines like Wegovy, Ozempic and Zepbound — directly from the companies that make them. The discounts use most favored nation (MFN) pricing, which ties US prices to the lowest prices in other developed countries.
The program operates entirely outside insurance: Patients download a coupon and then buy the medication at a pharmacy or on the manufacturer's website. No PBM is involved, and no claims data is returned to the employer.
Some organizations have been exploring similar direct pathways, issuing debit cards so employees can purchase medications straight from manufacturers. "Once people go off plan and get drugs directly from manufacturers, you have no idea what other medications they are on or whether there are missed opportunities for coordinated care. And without claims data, employers can't evaluate outcomes or forecast costs, which makes it harder to run the benefit responsibly," Friedman notes.
While clinical oversight vanishes, a hybrid model offers a real best-of-both-worlds opportunity, combining D2C pricing advantages with health plan clinical oversight and use reporting.
The new employer playbook
Multiple changes are happening simultaneously. On the one hand, D2C channels give employees a reason to circumvent health plans, and state laws change what PBMs can charge. On the other hand, PBMs are responding with fees and formulary restrictions as GLP-1 demand continues growing.
To defend against budget spikes, the goal is to adopt a proactive posture, where employers can leverage clinical data and contract governance to drive both employee health and fiscal sustainability.
This means auditing PBM contracts against new state requirements, assessing whether the health plan's pricing is competitive compared with D2C alternatives, and demanding transparency in formulary and rebate decisions. "This didn't really add value and only made things harder for patients," Friedman observes that the industry trend is moving toward the elimination of prior authorizations.
Planning ahead
The pharmacy benefit landscape will continue to evolve. Smart integration of clinical management, contract oversight and pricing intelligence will become the cornerstone of sustainable pharmacy strategy.
Employers that find a PBM that matches their culture and goals, and align health plan design with emerging state requirements, will be better positioned to manage escalating specialty drug costs while supporting long-term employee health.
"Don't open GLP‑1 coverage without a strong support program because costs can escalate fast. A thoughtful approach is essential to keep benefits sustainable," advises Friedman to these employers considering GLP-1 coverage for the first time.
