GPBCH Session Spotlights Barriers and Solutions in GLP-1 Affordability

Prescription drug costs in the US remain among the highest in the world, and despite breakthrough therapies that transform care for chronic and complex conditions, affordability continues to lag behind innovation. Patients, employers, and health plans alike are grappling with the strain of rising drug expenditures, compounded by aggressive pharmaceutical marketing and the complexity of the current pharmacy benefit structure.

Rising prescription drug costs challenge US health care, prompting calls for reform and innovative solutions to enhance affordability and access for patients. | Image credit: Cynthia - stock.adobe.com

Against this backdrop, the Greater Philadelphia Business Coalition on Health Annual Conference featured the session “Merging Traffic: GLP-1s & Medical Pharmacy,” led by Reetika Kumar, MD, senior vice president, chief customer product, clinical solutions, and pharmacy services at Independence Blue Cross (IBX). Drawing on nearly 3 decades of experience across clinical and business roles, Kumar called for structural reform in prescription drug pricing and access, arguing that both pharmacy benefit managers (PBMs) and pharmaceutical manufacturers have contributed to an opaque and inefficient system.

Kumar opened by underscoring how drug spending drives both medical and pharmacy costs, pointing to stark price discrepancies between the US and other countries. She recalled her experience in India, where a month’s supply of a therapy cost $100 compared with exponentially higher US prices.

“As someone who is passionate about health equity… I feel like we're also creating a health equity crisis here because 70% of Americans get access to treatments and health care through their employers or through state-funded plans and Medicare.”

Direct-to-consumer advertising also came under scrutiny. Kumar argued that aggressive pharmaceutical marketing, particularly for glucagon-like peptide-1

(GLP-1) agonists has fueled patient demand and contributed to what she described as a crisis of access and affordability. She noted that major manufacturers have spent heavily to promote GLP-1s for diabetes and weight loss, resources she suggested could instead lower drug prices and expand equitable access.

Turning to solutions, Kumar described the formation of Evio, a company established by 5 Blue Cross Blue Shield plans to disrupt the PBM-driven value chain. By contracting directly with manufacturers, Evio has introduced biosimilars at significantly lower prices. Kumar highlighted the case of a Humira biosimilar brought to market for under $600 and credited biosimilar transition programs with generating more than $128 million in client savings. Within 30 days of 1 transition initiative, over 90% of members were moved to a biosimilar, preventing cost spikes for those who remained on the originator product. She added that similar approaches are being implemented with biosimilars for ustekinumab and tocilizumab.

Still, challenges remain. Kumar emphasized the strain GLP-1 utilization is placing on emergency department resources and overall health system spending, noting that many patients are paying out of pocket to bypass coverage barriers. This, she argued, has created troubling parallels to earlier crises in opioid prescribing. Employers, who cover health care for 70% of Americans, face difficult decisions about how to manage demand for weight loss therapies while maintaining benefit equity. Kumar stressed the need for comprehensive obesity treatment strategies that integrate lifestyle modification, exercise, and nutrition counseling rather than relying solely on costly drugs.

“Obesity is a very complex chronic condition, and, as a physician, you want to set that person up for success. But by giving them a band-aid drug, you're not fixing the problem. You need to make sure you find out why they have a weight problem. Is it perimenopause or hormonal? Is it emotional eating? Could they be at risk for an eating disorder? Because what we were seeing happen is the prescribing of these drugs without truly evaluating the patient and managing them is leading to more people with anorexia,” she emphasized.

Kumar also raised concerns about pharmaceutical companies’ fiduciary behavior, citing clawbacks of rebates when payers attempt to manage drug use responsibly. She referenced recent Institute for Clinical and Economic Review findings showing that GLP-1s cannot be cost-effective at current US prices given their likely lifelong use. Broader reform, she argued, will require both federal action and state-level scrutiny of pricing practices.

Towards the end of the session, Kumar critiqued the FDA’s reliance on accelerated approval pathways, warning that reliance on surrogate endpoints without proven clinical benefit undermines payer decision-making and patient trust. She urged greater accountability and transparency, stressing that scarce health care resources must be directed to therapies that deliver demonstrable value.

Kumar concluded by announcing a new medical-side copay card program projected to yield 20% savings on specialty drugs. She invited employers and other stakeholders to consider this initiative as one of several strategies aimed at making health care more sustainable, equitable, and transparent.

Reference

Kumar R. Merging Traffic: GLP1s & Medical Pharmacy. GPBCH. Presented at: GPBCH Annual Conference; June 5, 2025; Philadelphia, PA.