Episode 61 - GLP-1s, Biosimilars and Pharmacy Spend: Insights From Employers Health's Book of Business

The episode opens with a deep dive into GLP‑1 trends that dominate pharmacy spend for many employers. Roughly 60% of plan sponsors now cover weight‑loss agents, but the surge in per‑member‑per‑month (PMPM) costs—about $30 before rebates—has forced a rapid shift toward stricter prior‑authorization protocols. Recent announcements from Novo Nordisk to slash list prices by 35‑50% for 2027, alongside Eli Lilly’s lower‑priced oral GLP‑1, promise front‑end savings for members, especially those on coinsurance, while simultaneously reducing rebate volumes that many employers rely on for premium offsetting.

Hannah explains how the clinical team leverages analytics to design custom utilization‑management programs, such as a new continuous‑glucose‑monitor prior‑authorization aligned with ADA guidelines. By slicing data in real time, the team can deploy guardrails before utilization spikes, minimizing member disruption. The discussion highlights a dramatic drop in unmanaged weight‑loss coverage—from 15% of clients without any prior‑auth to under 2%—demonstrating how data‑driven clinical strategies are reshaping cost‑avoidance tactics across the employer health landscape.

The conversation then shifts to autoimmune specialty spend, which accounts for $42 of the $101 average specialty PMPM. High‑cost biologics like Skyrizi, Dupixent, and Stelara dominate the top‑ten spend list, but biosimilar adoption is delivering measurable savings. A Stelara biosimilar transition rate of 90% has generated roughly $1.30 PMPM in upfront savings, with rebate reductions remaining modest compared to cost cuts. The hosts warn plan sponsors to monitor rebate‑guarantee structures as more classes, including HIV, move out of specialty tiers, underscoring the need for agile contract negotiations and continued analytics support.