Pharmacy Benefit Plans FAQ for Employers

You asked. OneDigital answered. 

Pharmacy benefit plans are evolving rapidly as employers face rising specialty drug costs, increased utilization, and growing pressure for transparency. From GLP-1 demand to supply chain disruptions and PBM dynamics, employers are seeking clearer strategies to manage cost, access, and long-term sustainability.

What is driving the rapid increase in pharmacy costs today?

Employers are seeing pharmacy costs rise due to several key factors: 

Specialty drug growth:

Specialty medications now account for a significant portion of total pharmacy spend, driven by high-cost therapies and expanded treatment use. 

GLP-1 utilization:

Medications such as semaglutide-based therapies are increasing demand across both diabetes and weight management populations. 

Increased utilization:

More members are accessing medications due to broader indications and improved diagnosis rates. 

Key takeaway:

Pharmacy cost growth is being driven by both higher prices and increased utilization, requiring a more proactive and strategic approach. 

How are GLP-1 medications impacting employer health plans?

GLP-1 medications have become one of the most significant cost drivers in pharmacy benefit plans. 

Rising demand:

Utilization has expanded beyond diabetes into weight management, increasing total plan exposure. 

High cost per claimant:

These therapies often require long-term use, compounding costs over time. 

Plan considerations: 
Employers are evaluating: 

• Coverage criteria and eligibility requirements  
• Prior authorization and clinical guidelines  
• Long-term cost sustainability  

Key takeaway:

GLP-1 strategies must balance access, clinical value, and financial sustainability. 

Are drug shortages still impacting pharmacy strategy?

Yes, while broad disruptions have stabilized, targeted drug shortages remain a concern. 

Ongoing challenges include: 

• Manufacturing constraints  
• Global supply dependencies  
• Demand surges for high-use therapies  

Employer impact: 

• Cost volatility for certain medications  
• Need for alternative sourcing strategies  
• Increased reliance on formulary management  

PBM response: 

• Therapeutic alternatives  
• Prior authorization controls  
• Quantity limits  

Key takeaway:

Drug shortages are no longer pandemic-driven but continue to require active management and strategic oversight. 

What should employers know about PBM transparency and pricing?

Employers are increasingly focused on understanding how pharmacy benefit managers (PBMs) influence cost. 

Key considerations: 

• Rebate structures and how they impact net cost  
• Spread pricing and contract transparency  
• Alignment between PBM incentives and employer goals  

Emerging trend:

Employers are evaluating alternative PBM models that provide greater visibility and control over pharmacy spend. 

Key takeaway:

Transparency is critical to understanding true pharmacy costs and making informed decisions. 

What should employers be doing now from a pharmacy strategy perspective?

Employers should take a proactive, data-driven approach to pharmacy strategy: 

• Evaluate specialty drug and GLP-1 cost exposure  
• Monitor formulary placement and utilization management  
• Assess PBM contracts and pricing transparency  
• Leverage vendor partnerships for:  
  • Cost containment  
  • clinical appropriateness  

As pharmacy strategies continue to evolve, employers that take a proactive and data-informed approach are better positioned to manage costs, improve outcomes, and reduce risk over time. 

As pharmacy strategies continue to evolve, employers that take a proactive and data-informed approach are better positioned to manage costs, improve outcomes, and reduce risk over time. 

Connect with a OneDigital Pharmacy Benefits Expert to evaluate your strategy and identify cost-saving opportunities.