In the Wake of the GLP-1s, Is It Time to Revisit Your Cost Share Strategy?

Most payers can expect the percentage of member cost share to decrease over time. This is because most plans use fixed or flat copays that are not updated to keep pace with increasing list prices of prescription drugs. While coinsurance plan designs have made some traction over the years, they still are not as common as the fixed or flat dollar amounts.¹ For example, National CooperativeRx groups saw an average member cost share of just $51.86 for a retail (non-specialty) brand drug last year. With an average ingredient drug cost of $591.41, that amounts to only an 8.8% member cost share.

It does not take long for a plan design to be undermined by time and see the member responsibility of overall costs eroded due to a variety of factors. For instance, the market launch price of new-to-market drugs continues to rise; in 2023, pharmaceutical companies launched new U.S. drugs at prices 35% higher than in 2022.² If this was not bad enough, Reuters also reported in 2024, per-unit costs for branded drugs rose by an average of 7%, up from a 5% increase in 2023.³ Drug makers also leverage need and non-need-based copay assistance programs which may undermine plan designs.

While most pharmacy benefit managers (PBMs) offer copay card programs for specialty drugs and many plan sponsors utilize them, such PBM offerings are much less common for non-specialty drugs, like the newer migraine drugs (CGRPs) or the diabetes and weight loss drugs (GLP-1s). It is not because the drug makers do not have copay card programs but rather because PBMs see a lower ROI per transaction for these programs; higher claims volume and lower relative copay card values.  

In the case of cost share for GLP-1s, drug makers may cover $150 to $225 per month with participants paying as little as $0 to $25 per month—despite monthly costs for these products ranging from $1,000 to $1,500. While these programs may be subject to change at the whim of drug makers, payers should still keep them in mind. The impact of the GLP-1s on plans is just heating up, with drug spend and claims volume on these products expected to rise in the coming years. Expect demand to continue with new and expanded (supplemental and/or added) approved indications.

Given the recent and anticipated future growth of the GLP-1s, payers should consider structuring their preferred brand (tier-2) cost share with this class of drugs in mind. For example, a retail (non-specialty) preferred brand cost share of at least $150 or a coinsurance of at least 15%. Adjustments to plan accumulations (deductibles and/or out-of-pocket maximums) may also be appropriate for sound plan designs. 

Formulary, generic incentives, and other elements payers may want to consider include utilization management strategies, wellness programs, health savings, and/or flexible spending accounts.

To implement these changes effectively, plan sponsors need a partner that understands the nuances of pharmacy benefit plan design. National CooperativeRx specializes in strategic plan design to balance cost management with high-quality care. Our account management team can help plan sponsors tailor plan designs to stand the test of time, driving savings and improved outcomes. Please contact your dedicated National CooperativeRx account representative to learn more and explore the best strategies for your plan.