Our Take
The coaching requirement and specialty PBM structure matter more than the GLP-1s themselves for cost control.
Why it matters
Benefits leaders need concrete strategies to manage GLP-1 spending that has grown 500% since 2018 (per JAMA). This shows measurable ROI from program design rather than blanket coverage.
Do this week
Benefits leaders: Audit your current GLP-1 coverage structure before next plan year to identify opportunities for specialty PBM partnerships with coaching requirements.
Specialty PBM structure delivers measurable diabetes outcomes
Conner Insurance partnered with Northwind Health Company and Spire Wellness to move diabetic medications including GLP-1s off a client's standard pharmacy benefit manager into a specialty PBM program. The program required mandatory health coaching in exchange for cutting brand-name drug co-pays in half and eliminating generic co-pays entirely.
Results after one year: $1 million in medical spend savings, 19% decrease in per-member costs for diabetic employees, A1C levels dropping from 11.3 to 8.5 among highest-risk participants, and 60% of participants trending toward diabetic remission (all company-reported). Buy-in among the diabetic population reached 90%.
The approach treats diabetes management like cancer treatment. "If someone is on chemo and they go into remission, they're going to go into a different treatment regimen. We approach diabetes the same way," said Ben Conner, CEO of Conner Insurance.
GLP-1 spending lacks clear ROI without structure
Diabetes medications cost employers roughly 10 times more than any other condition category (per Conner's book of business analysis). Meanwhile, GLP-1 spending increased 500% between 2018 and 2023, surpassing $70 billion (per JAMA).
The weight-loss focus has obscured GLP-1s' diabetes management role. Betsy Bigler, president of Northwind Health Company, noted manufacturers "want employers to cover these medications, no questions asked" without confirming diabetes diagnosis or tracking outcomes.
Without program structure, employers carry GLP-1 costs across three use cases with different ROI profiles: Type 2 diabetes management, prediabetes prevention, and weight management.
Baseline measurement enables program success
The specialty PBM approach requires defining measurable objectives upfront. Kelly Fenol from Spire Wellness emphasized establishing baselines: "If you don't know where you're starting, how are you ever going to get a delta?"
Key performance indicators include percentage of high-risk diabetic employees, GLP-1 fill rates, engagement percentages, and cost per patient. The program tracked which employees were taking medications for diabetes management versus weight loss, enabling targeted interventions.
The mandatory coaching component addresses medication adherence and lifestyle factors. Participants receive ongoing support for medication management, dietary changes, and exercise programs, creating accountability beyond prescription coverage.