Waiting for Your PBM to Tell You What Changed Isn’t a Strategy
Most plan sponsors receive annual formulary updates from their PBM, review the member disruption report, and move forward. What they often don’t receive is the financial analysis behind those changes: the net cost impact, the alternatives that were considered, or whether those decisions truly align with the plan’s clinical and financial goals.
In this article, Michelle Kamprath, Head of Clinical & Analytic Strategy at Expion Health, explores why passive formulary management can leave plans vulnerable to unnecessary costs and missed opportunities. Drawing on her expertise in pharmacy outcomes and pharmacoeconomics, Michelle examines the hidden drivers of pharmacy spend, from formulary leakage and high-cost generics to specialty medications and GLP-1 therapies, and outlines practical steps plan sponsors can take to gain greater control over their pharmacy strategy.
The Medicare GLP-1 conversation just entered a new phase.
Starting July 1, 2026, CMS will launch the Medicare GLP-1 Bridge, a short-term demonstration program expanding access to select GLP-1 therapies for eligible Medicare beneficiaries who do not currently have coverage for weight loss and weight reduction maintenance.
The structure is notable:
📌 Coverage sits outside the standard Part D benefit
📌 No Part D deductible applies
📌 Beneficiaries pay a flat $50 copay
📌 Part D sponsors assume no financial risk
📌 CMS manages prior authorization, claims, and pharmacy reimbursement through a centralized processor
Beyond expanding access, the program creates a real-world test case for how the healthcare system approaches one of the fastest growing and most financially consequential drug categories.
As GLP-1 utilization continues to accelerate, the question is no longer whether these therapies will reshape prescription economics. The question is how stakeholders will balance access, affordability, outcomes, and accountability at scale.
For more information on the program, visit the link below.
Follow @Expion Health for more updates from our regulatory expert @Scott Dunham.
