Despite steady demand for obesity medications, 49% of payers who do not currently cover GLP-1s for obesity would not do so at any price, a new report from Pharmaceutical Strategies Group (PSG) found.
The 2026 Trends in Drug Benefit Design report drew insights from a survey of 237 benefits leaders across employers, health plans and unions.
Nine in 10 respondents in the survey report being moderately or very concerned about the affordability of GLP-1 medications. Moreover, 72% report discontinuation rates are at least moderately influential in coverage decisions.
When asked the top reason for excluding coverage for obesity, 45% report coverage is too expensive for all members who would be prescribed the medication. Other factors include view of the medications as lifestyle drugs (24%), ongoing cost exposure (18%) and high discontinuation rates resulting in a lack of ROI (5%). Analysts note 9% of respondents selected “other” and described different reasons for excluding coverage.
For plans that are open to GLP-1 coverage for obesity, the average amount they are willing to pay annually is $3,000.
"As drug costs climb, payers are under pressure to re-evaluate benefit design and cost management strategies," said Morgan Lee, PSG vice president of research and marketing, in a statement. "The debate around GLP-1 coverage is a prime example of the balancing act benefits leaders face as they navigate skyrocketing demand, affordability concerns, and uncertainty around long-term patient outcomes."
Analysts note payers are progressively weighing partially or fully unbundling pharmacy benefit manager (PBM) services to maintain costs and increase transparency, with 60% of health plans and 51% of employers reporting they would consider a partially or fully unbundled model.
The perceived value of such models also increased among both payers and employers alike.
"We’re seeing payers turn to carveouts and unbundled PBM models as they look for more transparency and control in how their pharmacy benefits are managed," said Josh Van Ginkel, PSG vice president of plan sponsor consulting. "These arrangements have the potential to reshape how organizations approach vendor coordination, pricing visibility, and benefit oversight."
There are alternatives to traditional PBM pricing arrangements now on the market, and nearly all health plans and most employers had heard of cost-plus, pass-through pricing, and PMPM guarantee arrangements, according to the report. Sixty-one percent of payers are using pass-through pricing, and 36% of employers are. About one in 10 payers have a cost-plus arrangement or PMPM pricing guarantee, and the primary factors influencing decisions about these alternative pricing models are impact on total net pharmacy cost and member affordability and experience, the report found.
As costs continue to rise, many payers are contemplating increasing cost sharing for members. The report found that 69% of respondents were considering at least one change to their cost sharing with 43% considering increasing copay or coinsurance amounts. While cost-sharing transparency tools aim to help members manage their cost sharing, most payers perceive only moderate value in these tools and believe they are used by small percentages of members.
The report also looked at direct-to-consumer offerings, with 91% of respondents reporting awareness of GoodRx—though analysts note awareness of newer programs like TrumpRx, Cost Plus Drugs and LillyDirect or NovoCare is lower, at 66%, 64% and 54%, respectively.
About half of payers currently use strategies related to discount card or direct-to-consumer offerings. Employers and health plans cited some concerns about these offerings, with member confusion rising to the top as the most commonly cited concern, followed by loss of claims visibility.