PBMs, Pricing, and Policy: The Fight for Fair Access to GLP-1s

As the cost of health care continues to rise, access to life-changing medications remains a pressing issue for patients and providers alike. Glucagon-like peptide-1 (GLP-1) receptor agonists have emerged as powerful treatments for obesity and type 2 diabetes, with growing potential for additional therapeutic applications. However, despite their clinical benefits, the high cost of these medications—paired with restrictive insurance coverage—has left many patients unable to access them.

Piles of Wegovy infusion pens | Image Credit: © Patrick Bay Damsted - stock.adobe.com

This challenge is deeply intertwined with the role of pharmacy benefit managers (PBMs), whose pricing strategies and formulary decisions significantly impact which patients can afford GLP-1 therapies. As policymakers and industry leaders push for PBM reform, the future of GLP-1 accessibility hangs in the balance, raising critical questions about the intersection of cost, coverage, and patient care.

GLP-1s have taken patients and health care providers by storm, demonstrating significant success in the treatment of obesity and type 2 diabetes. However, research is uncovering potential benefits for additional conditions, including alcohol use disorder, nonalcoholic fatty liver disease (NAFLD), and even neurodegenerative disorders such as Parkinson’s disease. For instance, studies suggest that GLP-1s may help regulate appetite and cravings in alcohol use disorder, improve liver function in NAFLD, and reduce neuroinflammation in Parkinson’s disease. As their use expands, ensuring access to these agents is key.^1,2

GLP-1 therapies, such as Ozempic, Wegovy, and Zepbound, are very expensive, pricing out many patients who could greatly benefit from them. Historically, health insurance has not covered GLP-1s for weight management or weight loss, which is one of their most common uses.

“If we look at the employers we serve, only about 10% have coverage for weight loss at all under their plans; 90% have historically not offered any type of coverage, even on the medical side, for treatment of obesity or weight loss,” explained Leann Boyd, PharmD, former independent community pharmacist and founder of Liviniti, in an interview. “With the introduction of the GLP-1s and their effectiveness, there's a lot of demand out there.”

PBMs have become a substantial topic of debate over the past decade as patients and health care providers advocate for improved transparency, fair pricing, and better access to therapies, including GLP-1s. They occupy a central role in the drug price supply chain, acting as intermediaries between drug companies, insurers, and pharmacies to determine which drugs will be most available and what they will cost. While PBMs negotiate drug prices and rebates with manufacturers to control costs, critics argue that these savings often do not translate into lower out-of-pocket costs for patients.¹

PBM reform has emerged as a critical issue in the effort to improve patient access to essential medications, including GLP-1 receptor agonists. Government agencies, health experts, and patient advocates have increasingly called for transparency in drug pricing and formulary decisions as the cost of care rises. Patients and health care providers have raised the alarm, advocating for improved transparency, fair pricing, and better access to critical therapies. However, PBM reform isn’t linear—it requires dynamic legislative action to ensure transparency and fairness in health care.¹

“PBM’s being so complex, if you only fix one part of it, it allows for interesting practices to pop up in other areas,” said Boyd. “So, it's really looking more comprehensively at PBM and addressing every bit of that. That way, it truly makes a change.”

Health care providers discussing drug costs | Image Credit: © NINENII - stock.adobe.com

For GLP-1s, PBM reform could mean greater access to weight management and metabolic treatments as insurers reassess coverage policies in response to regulatory changes. By shifting toward cost-effective incentives for patients, reforms could help reduce financial barriers that have kept these therapies out of reach for many who need them. However, the extent of these benefits will depend on how PBMs, insurers, and drug manufacturers adapt to the evolving landscape, particularly as demand for GLP-1s continues to surge across multiple therapeutic areas.¹

“For a fully integrated health care enterprise, the PBM is just one of many tentacles to the margin-producing equation,” Troy Trygstad, PharmD, PhD, MBA, Pharmacy Times Editor in Chief, wrote in an article for Pharmacy Times. “In other words, maybe there isn’t a margin to be made in filling GLP-1s if all pharmacies are reimbursed at equally low or below-cost levels. Rather, the profitability for both PBMs and the plan sponsors lies in the rebates.”⁴

Over the past few years, there have been various attempts to hold PBMs accountable for unfair practices, such as spread pricing. The FTC has filed multiple lawsuits against Caremark Rx, LLC; Express Scripts, Inc.; and OptumRx, Inc., finding that the PBMs were responsible for significant price markups and other unfair practices. Regulatory scrutiny has intensified, reflecting broader concerns about how PBM practices contribute to drug affordability challenges.¹

During the Biden administration, President Joseph R. Biden, Jr signed the Inflation Reduction Act (IRA) in 2022, which allowed Medicare to negotiate drug prices for the first time. Before the end of his presidency, he signed Executive Order 14087 to expand the actions of the IRA. However, this was later rescinded by President Donald Trump, who instead signed the Making America Healthy Again by Empowering Patients with Clear, Accurate, and Actionable Healthcare Pricing Information executive order (EO), which aimed to force hospitals and corporate entities to disclose actual health care costs.^4,5

But is price transparency enough? Boyd and other health experts think this is a step in the right direction, but not a solution to lower health costs or increase patient access to care.

“Reform is truly how do we change the models and how do we truly bend pricing? And I just don't think reporting is going to get us there,” said Boyd. “So, while that might be a step in the right direction, it’s not enough. I’m looking for more tangible changes to the industry and how it practices.”

The push for PBM reform represents a pivotal moment in the effort to make life-changing medications like GLP-1s more accessible and affordable. Although regulatory actions and policy changes have begun to address the challenges posed by PBM practices, the path to true affordability and transparency remains complex. Meaningful reform will require continued collaboration between policymakers, health care providers, insurers, and patient advocates to dismantle cost barriers and ensure that coverage decisions prioritize patient outcomes over profit margins. As the demand for GLP-1 therapies continues to rise, the future of equitable access will depend on the ability to balance innovation, affordability, and accountability within the pharmaceutical supply chain.

“I think everyone is in the same boat of trying to find and address that affordability and access, and transparent models will continue to support that,” Boyd concluded. “More innovative programs for therapies like GLP-1s will help ensure we balance that cost equation to sustain the cost of that growing pipeline long term.”

REFERENCES

1. PBM reform: Tackling transparency, pricing, and patient access. Pharmacy Times. March 6, 2025. Accessed March 19, 2025. https://www.pharmacytimes.com/view/pbm-reform-tackling-transparency-pricing-and-patient-access

2. Five unexpected new uses for GLP-1 receptor agonists. Pharmacy Times. May 23, 2024. Accessed March 19, 2025. https://www.pharmacytimes.com/view/five-unexpected-new-uses-for-glp-1-receptor-agonists

3. Are PBMs putting GLP-1 drugs on their formularies? Managed Healthcare Executive. October 11, 2024. Accessed March 19, 2025. https://www.managedhealthcareexecutive.com/view/are-pbms-putting-obesity-drugs-on-formulary-

4. Two surprising developments in 1 week shake up the PBM mail-order business. Pharmacy Times. January 16, 2025. Accessed March 19, 2025. https://www.pharmacytimes.com/view/two-surprising-developments-in-1-week-shake-up-the-pbm-mail-order-business

5. Reversal of executive order 14087 raises questions about future drug pricing reforms. Pharmacy Times. January 22, 2025. Accessed March 19, 2025. https://www.pharmacytimes.com/view/reversal-of-executive-order-14087-raises-questions-about-future-drug-pricing-reforms

6. Executive order advances price transparency efforts to lower health care costs. Pharmacy Times. March 14, 2025. Accessed March 19, 2025. https://www.pharmacytimes.com/view/executive-order-advances-price-transparency-efforts-to-lower-health-care-costs