With the rising costs of health care, we are committed more than ever to identifying opportunities for group savings. We also know it is our responsibility to balance quality and cost of care while offering access to the treatments our members need to get and stay healthy.
Our Pharmacy and Therapeutics (P&T) committee, which is comprised of local and community physicians and pharmacists, regularly reviews the medications on our formulary weighing both clinical benefit and cost management. With this review, drugs are added or removed from the formulary each year potentially shifting the coverage status for some drugs.
More about the formulary changes that will take effect January 1, 2026.
GLP-1 for Weight Loss
A recent analysis of the weight loss GLP-1s Wegovy, Zepbound and Saxenda showed that since 2021, the Health Plan’s spending on these medications has increased dramatically. In addition, research shows that 58% of people using these drugs do not stay on them long enough to achieve a level of weight loss that will positively impact their health.
Increased spending due to high utilization with minimal clinical benefit is not a sustainable model for our organization, or for our members, so we have made changes for how we will manage coverage for these weight loss GLP-1s.
Wegovy, Zepbound and Saxenda will no longer be on our list of covered drugs but can still be covered through an exception request as long as the prescriber can verify that the member meets our coverage criteria. Our coverage guidelines ensure that members who would benefit the most can access this drug while receiving vital nutrition and fitness education as well as support from their provider.
This impacts the Large Group Preferred Value Formulary and the Small Group and Individual Market Closed Formulary. The 3-Tier Open Formulary and ESI National Preferred Formulary are not impacted by this update.
Additionally, these three weight loss GLP-1 medications will continue to be covered for members currently using them, however the members will need to be recertified at the expiration of their current authorization. That authorization will follow the same criteria for coverage.
Formulary Tiering Description Changes
In our continued efforts to manage trend for our groups, and based on shifting market dynamics with generics, we are redefining our formulary tiering descriptions. Effective January 1, 2026 (or upon plan renewal as required by state law), select high-cost, low-clinical-value generics will move from Tier 1 and will now be listed as Tier 2 and 3.
This impacts 3-Tier Open Formulary, Preferred Value Formulary and Health Insurance Exchange Closed Formulary. ESI National Preferred Formulary is not impacted by this update.
Historically, generics provided affordable alternatives to brand-name drugs. As market conditions have shifted and prescription drug prices escalate, not all generic medications are considered cost effective.
With these changes, there are still many options for members to switch to alternative drugs that are proven just as safe and effective. For employer groups enrolled in our Pharmacy Concierge program, our clinical pharmacists will continue to review employer group claims and work with the member’s provider to identify the optimal alternative medication for affected members.
To prepare in advance for 2026 formulary changes, employer groups and members can review the formulary for 2026, which will be available on our website in mid-October.
We remain committed to balancing quality and cost of care while offering access to the treatments our members need to get and stay healthy. If you have any questions about these changes, please don’t hesitate to reach out to your account manager.
If your group is looking for employee resources related to these changes, get our "Support Your Employees’ Understanding of Their 3-Tier Pharmacy Benefits" flyer.
Support Your Employees’ Understanding Of Their 3-Tier Pharmacy Benefits
