Fully Insured Pharmacy Strategy — Benefits Intelligence
Benefits IntelligenceTool 5 of 38
Fully Insured Pharmacy Strategy
Evaluate your pharmacy benefit design within a fully insured arrangement and identify opportunities to reduce Rx cost.
Created by Corry Hull, REBC®, CSFS® for Employer Benefits IQ.
1.How well do you understand and actively manage your formulary design, tier structure, and step therapy requirements?
Formulary management is the primary lever for Rx cost control in a fully insured plan.
2.How effectively does your plan design incentivize generic and biosimilar utilization?
Generic dispensing rate (GDR) benchmark: 85%+. Biosimilar adoption is an emerging opportunity.
3.How well do you manage specialty drug costs, including site-of-care optimization and specialty pharmacy carve-outs?
Specialty drugs represent 50%+ of Rx spend for many groups. Site-of-care (hospital vs. specialty pharmacy) is a major cost driver.
4.How much visibility do you have into your carrier's PBM contract, rebate pass-through, and spread pricing?
Fully insured employers often have limited PBM transparency. Requesting rebate disclosure is a starting point.
5.How clearly defined is your policy on GLP-1 medications (Ozempic, Wegovy, Mounjaro) for weight management vs. diabetes?
GLP-1 coverage for weight management can add $1,000–$3,000 PEPM. A documented coverage policy is essential.
This tool provides educational decision support only. Results are not legal, tax, actuarial, or insurance advice. Validate all outputs against current plan documents, applicable law, and qualified professional guidance. Scoring version 1.0 · Reference year 2026.