” If it costs roughly $1500/month to allow employees to fill these drugs through your health plan & PBM, but it costs about 1/3 of that to go direct, then…duh, I think you know the answer here.”
By Cristy Gupton – 2018 & 2020 EBA Top Women in Benefits Advising/Charter Certified Health Rosetta Adviser
March 27, 2025
The number of health insurance options seems to be dwindling. That is, if you’re only looking for big name options like Blue Cross, United Healthcare, Cigna or Aetna. There’s definitely fewer viable options with that kind of name recognition. But, are brand names that important when you’re just trying to offer an attractive employee benefit? Or, should we be taking Buckminster Fuller’s advice to build something new that makes the old crap obsolete?
Buckminster Fuller was a scientist, inventor, writer, and, in my favorite description, a “futurist” during the Industrial Revolution and other significant periods in American history.
In fact, I’d encourage more and more employers to start asking questions about rising healthcare costs and stop accepting the standard answers like:
- “Medical Trend” is increasing
- The “medical loss ratio” of your plan is too high
- Your prescription drug spend is higher than other employers like you
- Your population is sicker, and you need to implement our “wellness program”
- Your employees are over-utilizing the emergency room, so that’s why you need your local hospital’s onsite clinic offering
Here’s the answer you need to give them for each one of those points —
The big carriers didn’t reach the gigantic size they are today by telling you the honest, transparent truth. They have nearly unlimited resources to make up almost anything that sounds good.
Furthermore, you’re at a distinct disadvantage if you purchase a fully insured plan from one of these big carriers. In most states, they are under no obligation to show you the data associated with the claims they’re making that have led to your next rate increase. That’s why you need to look off the beaten path for a level-funded plan or self-funded plan (if possible) where you’ll have an advisor to work with (not just a broker to sell you stuff) who can help you analyze data and make smarter funding decisions over time.
Here’s just one idea that will pay off big if you can swing it —
Two drug manufacturers, Eli Lilly and Novo Nordisk, decided to sell their blockbuster GLP-1 drugs (Mounjaro and Ozempic) to cash buyers for $499 for a month’s supply. Word on the street is that those drug makers want to stick it to the big bad pharmacy benefits managers who are raking in billions of middleman money…cha ching! There is no need for middlemen when you can buy directly from the manufacturer.
Well, this sets up a very interesting opportunity for employers. If it costs roughly $1500/month to allow employees to fill these drugs through your health plan & PBM, but it costs about 1/3 of that to go direct, then…duh, I think you know the answer here. Use the “found money” to set up a way to reimburse employees who need these drugs and can buy them direct. But, don’t stop there. For just a few dollars more, you need to pair payment for the drug with a program specifically designed to treat the condition with expert clinicians.
There are programs uniquely designed to produce the best possible outcomes for employees struggling with obesity and Type 2 Diabetes. These programs are staffed with a team of physicians, nurses, dietitians, pharmacists, and other healthcare professionals trained in obesity medicine. They will help your employee walk through a special treatment program that will likely end in “remission” from these disease states. Employees simply filling GLP-1 drugs because their regular doctor prescribed them are not getting this extra help.
It is your fiduciary duty to ensure that your health plan assets are not being squandered on treatment options that rarely produce positive clinical outcomes. Every study you will find is saying that employees who fill GLP-1 drugs the standard way drop a few quick pounds, and then they quit the drug, regaining the weight plus some. No good can come from that, and you’ve just wasted thousands of dollars from your health plan.
What’s even better is that programs like this include measures to address the root cause of the problem from the start — uncontrolled blood sugar. You can’t do that without data. The best way to measure blood sugar is this, a continuous glucose monitor —
Not knowing how certain foods affect your blood sugar is problem #1. Not solving the main problem while also trying to solve co-morbidities is going to lead to a failed experience. Guaranteed.
So, I’ve said all that to say this…we should talk. It doesn’t matter what type of health plan you currently have. There’s low-hanging fruit we can affect while strategizing on the bigger issues. Send me a message here on LinkedIn and let’s get started. There’s no reason to wait until your next renewal. Let’s tackle the low-hanging fruit now and that’ll hopefully change the game for your upcoming renewal season anyway.
Stay Healthy, Y’all!
(Cristy Gupton, a 3rd generation insurance expert, started Custom Benefits Solutions)
