Another GLP-1 Drug Access Model: Will a Co-Pay Cap Revolutionize Affordability?

High costs of GLP-1 receptor agonists like Wegovy and Zepbound—often exceeding $1,000 monthly—limit access for patients seeking effective obesity and diabetes treatments. These barriers fuel demand for innovative GLP-1 drug access models, from pharmacy benefit manager (PBM) initiatives to direct-to-consumer programs. This article analyzes the groundbreaking GLP-1 drug access model by Evernorth offering a $200 co-pay cap for Wegovy and Zepbound, launched on May 21, 2025. It explores how the PMB solution enhance affordability and access while addressing clinical and systemic challenges.

Evernorth’s Pharmacy Benefit Model

Evernorth, the health services division of The Cigna Group, launched a pioneering pharmacy benefit program to improve its GLP-1 drug access model. Through direct negotiations with manufacturers Novo Nordisk (Wegovy) and Eli Lilly (Zepbound), Evernorth caps patient co-pays at $200 monthly, saving up to $3,600 annually compared to manufacturer programs like NovoCare ($499/month) or LillyDirect ($349–$499/month). Effective July 1, 2025, the program offers:

• Cost Savings: Patients pay $200 monthly, applied to annual deductibles, easing financial burdens.

• Safety and Efficacy: Express Scripts ensures FDA-approved drugs with robust safety checks.

• Simplified Access: Automated prior authorizations speed up medication delivery.

• Pharmacy Options: Patients choose retail pharmacies or home delivery via EnGuide Pharmacy.

• Health Plan Benefits: Sponsors see reduced net prescription costs.

Evernorth builds on its EncircleRx ($200 million in savings since 2024) and EnReachRx programs, prioritizing patient access and safety.

Broader GLP-1 Drug Access Models

Several models address GLP-1 affordability and access:

1. Direct-to-Consumer Programs:

   • NovoCare Pharmacy: Novo Nordisk offers Wegovy at $499/month for uninsured patients, with home delivery and support like benefit verification.

   • LillyDirect: Eli Lilly provides Zepbound at $349–$499/month, targeting out-of-pocket payers.

   • These programs bypass insurance but cost more than Evernorth’s $200 cap, limiting appeal for insured patients.

2. PBM-Driven Formulary Decisions:

   • CVS Caremark Deal: On May 1, 2025, CVS Caremark, the largest U.S. PBM, prioritized Wegovy as its preferred GLP-1 drug on standard formularies, dropping Zepbound from coverage starting July 1, 2025. Negotiated for lower costs, this deal expands access to Wegovy for CVS Caremark’s commercial plan members. Wegovy is offered at $499/month for self-pay patients at CVS’s 9,000 pharmacies. Lilly countered by reducing Zepbound vial prices by $50 or more, setting doses at $349–$499/month. This shift may disrupt treatment for Zepbound users, as Zepbound offers 47% greater weight loss than Wegovy, but larger self-insured employers may retain Zepbound via customized formularies.

   • PBM strategies like this focus on cost reduction to broaden access.

3. Compounded Alternatives:

   • Hims & Hers offers compounded semaglutide at $399/month for uninsured patients. Evernorth’s lower co-pay for FDA-approved drugs may reduce demand for non-FDA-approved options due to safety concerns.

4. Employer-Sponsored Utilization Management:

   • Evernorth uses utilization management to ensure appropriate GLP-1 prescribing.

   • Tools like lifestyle interventions and digital monitoring lower discontinuation rates (over 50% within 12 months).

Analysis: Pros and Cons Relative to Evernorth’s Model

Evernorth’s $200 co-pay cap sets a high standard for GLP-1 drug access models, offering significant advantages over other approaches. Below are the pros and cons of each model compared to Evernorth’s capped copay initiative.

• Direct-to-Consumer Programs (NovoCare, LillyDirect):

  • Pros: Accessible to uninsured patients. Offer home delivery and support services like benefit verification. LillyDirect’s $349–$499/month pricing is competitive for Zepbound.

  • Cons: Higher costs ($349–$499/month) than Evernorth’s $200 cap, reducing affordability for insured patients. Lack integration with employer-sponsored plans, limiting scalability. No automated prior authorizations, slowing access compared to Evernorth’s streamlined process.

  • Comparison: Evernorth outperforms with lower costs, broader insurance integration, and faster access, making it more appealing for insured patients.

• PMB Models: CVS Caremark Deal:

  • Pros: Expands access to Wegovy for CVS Caremark’s commercial plan members. Matches NovoCare’s $499/month self-pay price, improving affordability for uninsured patients. Customized formularies allow some employers to retain Zepbound coverage.

  • Cons: Excludes Zepbound, disrupting treatment for users benefiting from its 47% greater weight loss. Limits patient choice compared to Evernorth’s inclusion of both Wegovy and Zepbound. Higher self-pay costs ($499/month) than Evernorth’s $200 cap.

  • Comparison: Evernorth’s model offers greater flexibility by covering both drugs and lower costs, avoiding disruptions caused by CVS Caremark’s restrictive formulary decision.

• Compounded Alternatives (Hims & Hers):

  • Pros: Affordable at $399/month for uninsured patients. Broadens access for those without coverage.

  • Cons: Non-FDA-approved formulations raise safety and efficacy concerns. Higher costs than Evernorth’s $200 cap. Limited clinical oversight compared to Evernorth’s safety checks.

  • Comparison: Evernorth’s use of FDA-approved drugs and lower co-pay provides superior safety and affordability, reducing the appeal of compounded options.

• Employer-Sponsored Utilization Management:

  • Pros: Ensures appropriate prescribing, reducing misuse. Digital tools and lifestyle interventions lower discontinuation rates, aligning with Evernorth’s EnReachRx program. Complements employer-sponsored plans.

  • Cons: Lacks the comprehensive cost reduction of Evernorth’s $200 cap. May not offer the same level of pharmacy flexibility or automated prior authorizations.

  • Comparison: Evernorth integrates utilization management with a broader set of benefits, including lower costs and pharmacy options, making it more robust.

Challenges Across Access Models:

• High GLP-1 costs (6.7% of drug spend in 2024) and a projected 73.1% utilization increase in 2025 strain payer budgets.

• Over 50% of patients discontinue within 12 months due to side effects or costs, requiring better support.

• PBM decisions, like CVS Caremark’s, create competition but may limit drug options.

• Balancing affordability with access remains critical.

Conclusion

Evernorth’s $200 co-pay cap is a leading GLP-1 drug access model with unmatched affordability, safety, and flexibility. It outperforms direct-to-consumer programs, CVS Caremark’s formulary decision, compounded alternatives, and basic utilization management by offering lower costs, broader drug coverage, and streamlined access. While other models expand access for uninsured patients or specific drugs, they fall short in cost, flexibility and management. Success depends on addressing discontinuation and managing costs. Evernorth’s model could shape the future of GLP-1 access models.