Employers Buckle Down on Pharmacy, Medical Costs

By Emily Boyle – As Americans’ increased use of glucagon-like peptide-1 medications to treat obesity continues to balloon pharmacy costs, employers are looking to tighten their coverage parameters to manage medical costs more broadly. But employees question whether their companies are doing enough to control the costs borne by employees. Of employer respondents to Marsh’s 2026 National Benefits Strategy Survey, 76% reported that managing pharmacy costs was either important or very important to them in the next 12 months. Read Full Article...

HVBA Article Summary

1. Employer Strategies for GLP-1 Coverage: Many employers are reassessing their approach to covering GLP-1 medications, particularly for weight loss, due to rising costs. While the proportion of employers considering or providing coverage for these drugs has increased, more are also imposing restrictions to control expenses. This cautious approach reflects a balancing act between recognizing the medications' effectiveness and managing financial pressures.

2. Rising Medical Costs Impact Both Employers and Employees: Employers are not only adjusting pharmacy benefits but also making broader changes to manage escalating medical costs. Actions include altering benefit funding, raising deductibles, and passing more costs onto employees. Despite these efforts, there is a notable disconnect between employers' perception of their cost-containment success and employees' experiences with financial stress related to healthcare expenses.

3. Employee Financial Stress and Organizational Responses: Surveys indicate that a significant portion of employees are experiencing financial stress, with medical costs being a major contributing factor. This stress can lead to employees delaying care, dropping benefits, or reconsidering retirement plans, which may ultimately affect workplace productivity and engagement. Employers facing substantial increases in medical costs are more likely to consider significant changes to their benefits offerings in the near future.

Sun Life increases medical stop-loss sales by 43%

By Allison Bell – Sun Life Financial has been increasing medical stop-loss insurance sales as some competitors have backed away from the market. Employers with self-insured health plans use medical stop-loss insurance to protect the plans from catastrophic claims and from the kinds of big, unexpected surges in smaller claims that might be caused by a bad influenza outbreak. Sun Life's U.S. medical stop-loss premium revenue rose 43% between the first quarter of 2025 and the first quarter of this year, to $63 million, the company reported last week. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Growth Amid Market Shifts: Sun Life has managed to significantly increase its medical stop-loss insurance sales at a time when some competitors are reducing their presence in this market. The company attributes its growth to a focus on acquiring high-quality business and maintaining strict underwriting standards. This suggests that Sun Life is targeting employers who actively manage health plan risks and are willing to pay for robust coverage.

2. Profit Margin Dynamics: Despite the strong performance of its stop-loss segment, Sun Life's overall group benefits profit margin declined due to weaker results in its dental and disability insurance lines. The company reported that while stop-loss continues to perform well, challenges in other group benefits products have offset these gains. This highlights the importance of product mix and the varying profitability within group insurance offerings.

3. Industry-Wide Trends: Other major insurers, such as Cigna and Voya, have also reported increases in stop-loss sales, though their public commentary on the segment has been limited. Voya, in particular, is facing external pressure regarding the future of its stop-loss business but has noted improved loss ratios. These trends indicate a broader industry interest in stop-loss insurance, with multiple providers experiencing growth and evolving strategies in response to market conditions.

Optum Rx unveils pharmacy model with clear fees, building on transparency push

By Shelby Livingston – UnitedHealth Group’s Optum Rx on Monday unveiled a new approach to prescription drug benefits that it said offers its customers transparency into the entire drug supply chain. Under the new model, launching in 2027, the pharmacy benefit manager will charge employers and health plans clear monthly fees per member that aren’t based on drug list prices or prescription volume. Optum said it will eliminate the practice of spread pricing, in which the PBM makes money by charging health plans more than it reimburses pharmacies and pocketing the difference. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Optum Introduces Transparent PBM Pricing Model: Optum Rx announced a new pharmacy benefit management model that moves reimbursement away from drug list prices and increases transparency around rebates and fees. The company said clients will be able to audit financial flows down to the drug level, including through its group purchasing organization, Emisar, which plans to transition to flat fees by the end of 2027. Optum stated that the model applies across all drugs and pharmacies and expands on earlier efforts such as rebate pass-throughs and cost-plus pricing.

2. Industry and Regulatory Pressure Drive PBM Changes: Pharmacy benefit managers have faced growing scrutiny from lawmakers, regulators, employers, and customers over concerns that rebate-driven pricing contributes to rising drug costs and limited transparency. Recent federal reforms will prohibit PBMs from profiting from rebates beginning in 2028 and require disclosure of revenue sources, while additional proposed rules could expand reporting requirements. Optum executives said the company’s new model aligns with broader market demand for transparent pharmacy benefit structures and positions the company ahead of future regulatory changes.

3. Optum Expands Consumer Tools While Maintaining Financial Targets: UnitedHealth is implementing the new pharmacy model during a broader corporate turnaround focused on improving operational performance and profitability. Optum executives said the company expects to maintain its current profit margins under the transparent pricing structure by improving client service and supporting business growth. As part of the rollout, Optum also introduced consumer-facing tools that provide real-time prescription pricing information, pharmacy options, and delivery choices immediately after a prescription is written.

Omada Health posts 42% revenue jump in Q1, joins Eli Lilly employer weight loss program

By Heather Landi – Omada Health reported revenue of $78 million in the first quarter, up 42% year over year as the company continues to expand its commercial reach and is seeing traction from its big investments in GLP-1 capabilities. The virtual chronic care provider reported strong adoption of its GLP-1 Care Track program while the company also continues to successfully sell multiple chronic condition programs to its existing customer base of employers and health plans, executives said during the company's Q1 earnings call on Thursday. Read Full Article...

HVBA Article Summary

1. Significant Revenue and Membership Growth: Omada Health experienced notable financial and operational gains in Q1 2026, with a 42% increase in revenue and a 51% rise in membership compared to the previous year. The company attributes this growth to strong adoption of its GLP-1 Care Track and the expansion of its multi-condition chronic care programs. These results indicate Omada's increasing influence in the digital health sector and its ability to scale its offerings to a broader employer and health plan market.

2. Strategic Partnerships and Expanded Offerings: Omada Health has broadened its reach through new partnerships, including joining Eli Lilly’s Employer Connect program and collaborating with major pharmacy benefit managers. These alliances allow Omada to offer employers multiple pathways for providing weight loss medications and coordinated lifestyle support. The company’s approach enables employers to tailor benefit designs to their needs, reflecting the growing demand for flexible, integrated cardiometabolic care solutions.

3. Investment in AI and Clinical Outcomes: Omada continues to invest heavily in artificial intelligence to enhance care delivery, automate operations, and improve efficiency across the organization. The company’s clinical analysis shows that members in its GLP-1 Care Track achieved greater weight and body fat loss compared to a control group, supporting the effectiveness of its wraparound care model. These advancements in technology and clinical outcomes are central to Omada’s strategy for sustaining growth and delivering value to employers and members.

Insured Americans are rationing care due to hidden financial struggles

By Alan Goforth – The visible metrics of employer-sponsored health care -- rising premiums, surging deductibles, increasing employee contributions and year-over-year cost hikes – are easy to quantify. However, the unseen financial and physical toll that often happens behind closed doors can be just as significant. "While enrollment remains stable, the functional utility of that insurance is declining," according to a new report from Paytient. "Many employees are technically covered but remain financially vulnerable." Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Hidden Financial Barriers Despite Coverage: Many Americans with employer-sponsored health insurance are still unable to afford necessary care due to high deductibles and out-of-pocket costs. This financial strain leads a significant portion of insured individuals to skip or delay medical treatment, undermining the intended benefits of having insurance. The issue highlights a disconnect between having coverage and being able to use it effectively.

2. Impact on Workplace Productivity and Culture: The financial challenges faced by employees are not only personal but also affect businesses and workplace culture. Employees who delay care due to cost concerns lose productivity—on average, more than six hours per week—and may experience shame or hide their struggles, sometimes taking on second jobs. This hidden crisis can result in presenteeism and a less engaged, less healthy workforce, which employers may not fully recognize.

3. Potential Solutions and the Importance of Affordability: The report suggests that the main barrier to accessing care is often a relatively small financial gap, typically less than $1,500. Addressing this liquidity gap—by ensuring employees have the means to pay for care when needed—could unlock better health outcomes and workforce potential. The findings argue that true access to health care requires more than just insurance enrollment; it demands practical affordability to support both employee well-being and organizational health.

AI-augmented behavioral health provider Theris launches out of stealth

By Anastassia Gliadkovskaya – Theris, an AI-powered behavioral health provider, has launched out of stealth with an update to its platform. The startup, founded in 2023, provides care and augments it with AI tools for providers, automating clinical workflows from intake to billing. As sessions take place, AI agents record and analyze sessions, with patient consent. The AI agents can surface details from a patient’s medical record that a provider missed or flag potential medication interactions, among other capabilities. Read Full Article...

HVBA Article Summary

1. AI Integration in Behavioral Health: Theris employs artificial intelligence to assist behavioral health providers by automating clinical workflows, analyzing patient sessions, and flagging important medical details. The platform uses digital biomarkers from voice and facial expressions to generate treatment recommendations and improve diagnostic accuracy. This integration aims to enhance the quality and efficiency of care while supporting providers in their daily tasks.

2. Patient Consent and Data Privacy: Theris emphasizes transparency and patient consent, requiring explicit permission before recording and analyzing therapy sessions. Less than 1% of patients opt out of these recordings, and all data is anonymized and not shared externally. The company prioritizes data sensitivity and uses anonymized session data to train its AI models, which have accumulated over 150,000 hours of clinical encounters.

3. Future Goals and Regulatory Ambitions: Theris is working toward FDA Class II medical device status, which would allow for fully autonomous psychotherapy and psychiatry services. The company anticipates that AI-driven mental health care could soon be reimbursed by insurers, expanding access to both AI-augmented and traditional therapy. Theris has also been accepted into the CMS ACCESS model, positioning itself to participate in value-based behavioral healthcare initiatives.

CVS hikes outlook as Aetna insurance profit rises

By Emily Olsen – CVS Health raised its full year revenue and earnings guidance Wednesday after performance in the healthcare behemoth’s Aetna insurance unit improved in the first quarter. The company now expects adjusted earnings per share from $7.30 to $7.50 in 2026, up from CVS’ previous estimate of $7 to $7.20. Revenue should reach at least $405 billion this year, increasing from the healthcare giant’s previous guide of at least $400 billion. The improved outlook comes after Aetna — which has struggled in recent years with heightened medical costs — saw revenue rise more than 3% in the first quarter. Read Full Article...

HVBA Article Summary

1. Aetna Drives CVS's Improved Financial Outlook: CVS Health's upgraded earnings and revenue guidance for 2026 is largely attributed to significant gains in its Aetna insurance unit. The insurance segment saw notable revenue and operating income growth, particularly due to improved performance in government plans and the conclusion of a large premium deficiency reserve. This turnaround is a relief for investors, as Aetna had previously faced challenges from increased medical spending, especially in Medicare Advantage plans.

2. Industry-Wide Positive Trends and Regulatory Changes: CVS is not alone in reporting better-than-expected first quarter results, as other major payers like UnitedHealth, Elevance, Cigna, and Centene have also raised their outlooks. The company’s health services segment, which includes its pharmacy benefit manager, experienced revenue growth but a decline in operating income due to pricing dynamics. Meanwhile, CVS and other firms with large PBMs are navigating new regulatory pressures, including a proposed FTC settlement and recent federal legislation introducing transparency and payment reforms.

3. Ongoing Challenges Despite Rate Increases: While CVS welcomed the finalized Medicare Advantage rate hike for 2027, company leadership indicated that the increase is still insufficient to fully address ongoing high medical cost trends. Executives noted that these elevated costs have pressured the entire industry for several years, and that further adjustments may be needed for long-term sustainability. CVS has proactively responded to anticipated policy changes by launching new drug pricing models and engaging with regulators to clarify future operational rules.

GLP-1 Semaglutide Promising for Alcohol Use Disorder

By Pauline Anderson – Once weekly semaglutide injections reduced alcohol consumption in patients with alcohol use disorder (AUD) and comorbid obesity. Results of the randomized controlled trial (RCT), the first, to the authors’ knowledge, to evaluate the GLP-1 receptor agonist (GLP-1RA) semaglutide in patients seeking treatment for AUD who had comorbid obesity also showed significant effects on multiple alcohol-related outcomes. “These data, when added to the growing evidence, demonstrate the potential of GLP-1RAs as a novel treatment for alcohol use disorder,” the investigators, led by Mette Kruse Klausen, MD, Copenhagen University Hospital in Copenhagen, Denmark, wrote. “However,” they added, “corroboration with larger RCTs in nonobese patients is needed to address its generalizability.” Read Full Article...

HVBA Article Summary

1. Semaglutide Shows Promise for Treating AUD in Patients With Obesity: The randomized controlled trial found that weekly semaglutide injections significantly reduced heavy drinking days and improved several alcohol-related outcomes in adults with both alcohol use disorder and obesity. These improvements included reductions in total alcohol consumption, number of drinks per drinking day, alcohol craving, and alcohol exposure biomarkers. The results suggest semaglutide could be a valuable addition to current treatment options for this population.

2. Potential for Broader Indications and Public Health Impact: The study’s findings support the possibility of expanding semaglutide’s approved uses to include alcohol use disorder, which could benefit millions of people worldwide who struggle with both AUD and obesity. Editorial commentary noted the relatively low number needed to treat, indicating that semaglutide’s efficacy may be comparable to or better than existing medications for AUD. If future studies confirm these results in more diverse populations, the drug could have substantial public health implications.

3. Safety Profile and Study Limitations: Most adverse events associated with semaglutide were mild to moderate gastrointestinal symptoms, and serious adverse events were rare and resolved by follow-up. However, the study only included participants with a BMI of 30 or higher, and the majority of participants were White, which limits the generalizability of the findings. The authors emphasize the need for further research, especially in non-obese and more diverse patient populations, and for longer-term follow-up on alcohol-related outcomes.