New Research Reveals Strategic Approaches to Balancing Member Access and Affordability with Pharmacy Spend Control
Pharmaceutical Strategies Group (“PSG”), an EPIC company, published its 2025 Trends in Drug Benefit Design Report, delivering critical insights into how payers are navigating a rapidly evolving pharmacy benefits landscape. For three decades, this industry report has been an essential resource for employers, health plans, and other stakeholders seeking to understand and adapt to changes in pharmacy benefit design and management.
The 2025 edition addresses both foundational benefit design elements — including formulary and network design, utilization management, and cost sharing — and today's most pressing challenges, such as GLP-1 coverage decisions, heightened fiduciary liability concerns, and the accelerating shift toward unbundled PBM arrangements. Drawing from extensive research and insights from benefits leaders nationwide, the report provides actionable intelligence for organizations working to balance member access and affordability with effective pharmacy spend control. Read all the insights in the full report available here.
Navigating the GLP-1 Surge
While nearly all plans cover GLP-1s for type 2 diabetes (92%), only 39% currently cover GLP-1s for obesity. Cost is a large concern for payers with respect to GLP-1s for obesity, but even so, the survey finds that nearly half of plans that currently exclude these drugs from coverage say they would not cover the drugs at any price. Benefits leaders must balance the overwhelming demand for these medications with their cost as well as the decision to cover a treatment for obesity.
“GLP-1s are the area of this report where we see the most variation in perception and strategy,” said Morgan Lee, Senior Director of Research & Strategy at PSG. “Respondents are very concerned about GLP-1 affordability for the plan, and many are concerned about off-label use of GLP-1s for type 2 diabetes, yet nearly half don’t know how much of their current spending is for off-label purposes. We’re also seeing continued variation in how plans perceive GLP-1s for obesity, whether as lifestyle drugs or as treatments for a chronic disease. As the GLP-1 landscape rapidly evolves with expanded indications, direct-to-consumer offerings, and more, payers will continue to have new considerations and decisions to navigate.”
Unbundling Pharmacy Benefit Management
One of the most disruptive strategies explored in the report is the shift toward unbundling PBM services. This year’s report revealed that a growing number of payers are evaluating or already pursuing this modular approach, which allows organizations to separate functions, such as claims processing, formulary management, and rebate negotiation, and contract them independently.
“We’re seeing rising interest in partial or fully modular PBM arrangements,” shared Beth Hebert-Silvia, Senior Vice President, Health Plans Practice Leader at PSG. “This strategy isn’t plug-and-play. It requires sophisticated design and execution, but it enables plans to align each element of their pharmacy benefit with their unique needs. More importantly, it empowers them with greater transparency and control.”
Rethinking Cost Sharing in a Price-Sensitive Era
Cost sharing remains the most visible and impactful element of pharmacy benefit design for members. According to the report, 70% of payers are contemplating changes to their cost sharing structures, with many exploring increases in copays, coinsurance, or deductibles. To help members manage their cost sharing, over half of payers promote cost-sharing transparency tools, although views are mixed on the effectiveness and value of these tools.
Employers Grapple with Fiduciary Risk and Future Investment
Many benefits leaders are concerned about exposure to fiduciary risk through pharmacy benefits and are taking steps to protect themselves. One in three employers report making moderate or large changes to their approach to fiduciary responsibility in light of recent lawsuits alleging mismanagement of pharmacy benefits.
“Employers are more alert than ever to the legal and financial responsibilities tied to benefit partnerships and decisions,” said Mike Medel, Senior Vice President and Practice Lead, Plan Sponsors at PSG. “We’re seeing employers invest more time in vendor selection, pricing models, and governance processes because they know the risks of fiduciary criticism are real and growing.”
The report also reveals that half of employers expect to increase their investment in benefits over the next one to two years, with pharmacy benefits ranking among the top three targeted areas for expansion. Read all the insights in the full report available here.
About the 2025 Trends in Drug Benefit Design Report
The Trends in Drug Benefit Design Report provides in-depth insights into traditional (non-specialty) drug benefit trends and strategies and focuses on drug benefit design for the 2025 benefit year among employers, union/Taft-Hartley, and health plan respondents. The survey sample informing this report included 222 benefits leaders. Issues specific to specialty drugs are included in a separate report — Trends in Specialty Drug Benefits. This report, as well as prior annual reports conducted by PSG, can be found at https://www.psgconsults.com/research.
About Pharmaceutical Strategies Group (PSG)
Pharmaceutical Strategies Group, an EPIC company, relentlessly advocates for clients as they navigate complex and ever-changing drug cost management challenges. PSG is an independent consultant, empowering healthcare payers to manage their pharmacy program better. As a strategic partner, PSG helps clients by providing industry-leading intelligence and technologies to realize billions of dollars in drug cost savings for clients every year. www.psgconsults.com
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Gregory FCA for PSG
EPIC@gregoryfca.com
