Evernorth launches the first PBM financial guarantee for GLP-1 spend

Evernorth Health Services, the health services arm of The Cigna Group, said on March 7, 2024 that it will offer employers and health plans the first financial guarantee in the industry for spending on GLP-1 drugs ^[1]. The guarantee is part of an expansion of Evernorth's EncircleRx program and gives clients a choice between a cost cap or a savings guarantee ^[1].

For participating employers and plans, annual increases in spending on GLP-1 receptor agonists would be limited to 15% ^[2]. That applies to Novo Nordisk's Wegovy (semaglutide) and Eli Lilly's Zepbound (tirzepatide), and is possible because of agreements Express Scripts, Evernorth's pharmacy benefit manager, struck with the two drugmakers ^[2]. Cigna has not disclosed the terms of those contracts ^[2].

The comparison point matters. A Cigna spokesperson told Healthcare Dive that health plans are currently seeing annual cost trend for weight loss drugs of 40% to 50% ^[2]. "It's a completely unsustainable number and our clients continue to look to us for help," Adam Kautzner, president of Express Scripts and Evernorth Care Management, said at the company's investor day ^[2].

What the program includes

EncircleRx is pitched as a package, not just a discount. Patients who meet the criteria for a GLP-1 are also enrolled in a lifestyle modification program with behavior change support from an Omada Health care team, aimed at outcomes like controlled A1C, weight loss, or reducing cardiovascular risk factors ^[1]. Evernorth frames the target as "cardiodiabesity" — the overlap of obesity, diabetes and cardiovascular disease — which it says represents about $838 billion in annual U.S. health care costs ^[1].

Evernorth also cited a pilot it ran with Omada Health and the Evernorth Research Institute. Among members in Omada for Prevention who had a baseline weight and at least one monthly follow-up weight, those who used GLP-1s and were more engaged in the program lost more weight than less-engaged GLP-1 users ^[1]. Evernorth said relationship-based engagement, such as working with a care team or other participants, drove more success than other forms of engagement ^[1]. The company did not publish the number of participants or the size of the weight difference in the announcement ^[1].

Importantly, the guarantee is not one-size-fits-all. A Cigna spokesperson said a client's specific guarantee differs based on "client type, depending on current benefit offerings and size of patient population, among other factors including specific client preferences and financial strategy" ^[2]. Specific eligibility rules — such as minimum employee counts or whether a plan already covered GLP-1s — were not spelled out in the company's announcement or in Healthcare Dive's report, so those details are not yet publicly confirmed.

Why it matters for patients

Whether an employer covers a GLP-1 for weight management is often the single biggest factor in what a patient pays. At the time of the announcement, only 25% of employers covered GLP-1s for weight management, according to a survey by care delivery company Accolade, and more than a third of employers cited cost as a barrier ^[2]. List prices were $1,349 a month for Wegovy and $1,060 a month for Zepbound ^[2].

Analysts told Healthcare Dive the cap could insulate employers from surging costs while increasing patient access ^[2]. But a 15% annual increase is still an increase. "It's a step forward. Is it enough? Maybe not, but in comparison to that 40% to 50% it feels like a much more palatable number," said Arielle Trzcinski, a principal analyst at Forrester ^[2].

There are two practical catches. First, the arrangement is between the PBM and employers or plans — it does not change a drug's list price or an individual's copay directly. Second, coverage under EncircleRx comes bundled with enrollment in the Omada lifestyle program for patients who meet GLP-1 criteria ^[1], so members at participating employers may encounter more program requirements alongside a prescription.

Supply was also a constraint at the time. Semaglutide injection remained in limited availability according to the FDA, and Healthcare Dive noted that shortages combined with low coverage rates were creating a bottleneck despite heavy demand ^[2].

What happens next

Evernorth announced the expansion on March 7, 2024, ahead of Cigna's investor day in New York, and later updated the release on November 25, 2024 ^[1]. The sources do not state how many employers signed up, how the 15% cap performed in practice, or whether the guarantee has been extended to other GLP-1 products. Those outcomes are not yet known from the available materials.