Here is an uncomfortable truth about benefits renewal: for most employers, it is not a negotiation at all. It is a cost-acceptance exercise with a few rounds of back-and-forth to make everyone feel better about the number they were always going to land on. The carrier knows what the claims data says. The employer does not. That information asymmetry determines who controls the conversation and in most mid-market renewal situations, it is not the employer.

Employers who consistently achieve better renewal outcomes do not negotiate harder. They eliminate the information asymmetry before the renewal conversation begins. They arrive at the carrier’s table with their own claims analysis, their own benchmark data, and a documented understanding of exactly which plan design levers would move their cost trend. That is not a harder negotiation. It is a different kind of conversation entirely.

What the Carrier Knows That You Probably Do Not

Your carrier receives your claims data on a monthly basis. Their actuaries have already modeled your projected claims trend, identified your high-cost claimants, categorized your specialty drug utilization, and set your renewal rate accordingly. When they present your renewal, they know precisely why it is what it is. When most employers receive that renewal, they know only the bottom line.

This gap is not accidental. Carriers benefit from employers who negotiate based on intuition rather than data, because intuition-based negotiation typically produces incremental concessions, such as a few percentage points of rate reduction, without addressing the underlying claims drivers. An employer who negotiates a renewal from a 12% increase down to 9% without addressing the high-cost claimant concentration or the specialty drug utilization driving the increase will receive another 10% renewal the following year.

The Three Data Sets That Actually Move Renewal Outcomes

Three specific categories of data change what is possible in a renewal conversation.

Claims trend analysis by category: Understanding whether your cost increase is driven by inpatient utilization, outpatient services, emergency department use, or pharmacy, and within pharmacy, by GLP-1 medications, specialty biologics, or retail fills, tells you which plan design levers are worth pulling. A carrier proposing a higher deductible to address a cost problem that is entirely driven by specialty pharmacy is proposing the wrong solution. You can only identify that mismatch if you have the claims data to show where your spend is actually concentrated.

High-cost claimant identification and management: In most mid-market employer health plans, 5% of members account for 50% or more of total claims cost. Identifying who those members are, not by name, but by condition category and care pattern, and connecting them to disease management programs, case management support, and high-value providers is the single highest-ROI intervention available in health plan management. Carriers have this data. They can be compelled to share it as part of the renewal process. Most employers never ask for it.

Benchmarking against peer employers: Knowing that your plan costs $18,500 per employee is useful only in the context of what comparable employers in your industry and geography are paying. If your peer group average is $16,800, you have a substantive basis for a plan design conversation. If your peer group average is $19,200, the conversation shifts toward understanding why your claims experience is favorable relative to market. Benchmarking data, by industry, by plan design type, by geographic market, is the context that transforms a renewal number from an isolated data point into a negotiating position.

What to Do in the Ninety Days Before Your Renewal Date

The renewal conversation is won or lost ninety days before the renewal date, not on the day the carrier presents its offer. The employers who consistently achieve favorable outcomes invest those ninety days in three things.

First, request your full claims data from your carrier or TPA. You are entitled to it. Analyze it by category, identify your top cost drivers, and isolate any outlier claims or claimants that are distorting your trend. This analysis tells you whether your renewal rate reflects a systemic cost problem or a one-time claims event, and those require different responses.

Second, benchmark your plan against current market data for comparable employers. The data analytics and benchmarking capabilities at Tooher-Ferraris provide employers with industry-specific benchmarking across plan design elements, cost-sharing structures, and utilization metrics that give the renewal conversation a factual foundation.

Third, develop a set of plan design alternatives before the carrier presents its renewal. These alternatives, adjusted deductibles, modified network structures, enhanced disease management requirements, pharmacy formulary changes, give you a response to a high renewal number that is not simply accepting it or shopping it elsewhere. They demonstrate to the carrier that you understand your claims drivers and are prepared to take action on them, which is the posture that produces substantive concessions rather than cosmetic ones.

Tooher-Ferraris works with employers to analyze claims data, develop benchmarking context, and build renewal strategies that reflect what the data actually shows about cost drivers and plan performance. Learn more at https://toofer.com/data-analytics-benchmarking/ and https://toofer.com/employee-benefits-strategy-and-consulting/.

Ready to approach your next benefits renewal as a data-driven negotiation? The team at Tooher-Ferraris has been helping employers build stronger renewal strategies since 1932. Contact us today to schedule a no-obligation consultation — https://toofer.com/contact-us/

The International Foundation of Employee Benefit Plans publishes annual benchmarking data on employer health plan costs and design at ifebp.org. SHRM’s employer health benefits resources, including plan design benchmarking, are available at shrm.org.

Frequently Asked Questions

What data should employers request from their carrier before renewal?

Employers should request a full claims experience report broken down by category, including inpatient, outpatient, emergency, and pharmacy, along with a high-cost claimant summary that is de-identified as required by regulation and shows the concentration of claims among the highest-cost members. Specialty drug utilization data, including the specific therapeutic categories driving pharmacy cost increases, is also essential for determining whether plan design changes or PBM contract adjustments are the appropriate response.

How does benefits benchmarking improve renewal outcomes?

Benchmarking establishes what comparable employers in your industry and geography are paying for similar plan designs. When your plan’s cost is above benchmark, you have a factual basis to challenge the carrier’s assumptions about expected claims trend. When your plan’s cost is below benchmark, the data helps you make an informed decision about whether to invest savings in plan design improvements or retain them as a cost advantage.

Why do most employers not use data in their renewal process?

The primary reason is access: most employers do not know they can request detailed claims experience data from their carrier, or they assume the data will be difficult to interpret without actuarial expertise. The second reason is timing: the data is most valuable when analyzed 60 to 90 days before renewal, but many employers do not begin the renewal process until they receive the carrier’s initial offer. By that point, the data can inform a response, but it is too late to support a proactive strategy.

 

Tooher-Ferraris Named a Top-Rated Benefits Consultant for 2026

We are proud to announce that Tooher-Ferraris Insurance Group has been named a Top-Rated Benefits Consultant for 2026 by Mployer, the industry leader in employee benefits analytics and research.

Fewer than 10% of benefits consulting firms nationwide receive this distinction. The recognition reflects our team’s experience, industry knowledge and commitment to helping employers build effective employee benefits programs.

What Is the Mployer Top-Rated Benefits Consultant Award?

Mployer evaluates employee benefits consultants using independent data and client feedback. Its evaluation considers factors such as a firm’s experience across different industries, employer sizes and plan designs, as well as client ratings and reviews.

The Top-Rated Benefits Consultant designation helps employers identify firms with a demonstrated ability to provide knowledgeable guidance, responsive service and effective benefits solutions.

For Tooher-Ferraris, this recognition validates the consultative approach we bring to every client relationship. Our goal is not simply to place coverage. We help employers understand their options, make informed decisions and develop benefits programs that support their financial and workforce objectives.

Learn more about our employee benefits services.

 

What This Recognition Means for Our Clients

While we are honored to receive this award, its greatest significance is what it represents for the organizations we serve.

Proven Experience

Employee benefits decisions affect an organization’s finances, ability to recruit and retain employees and overall employee experience. Clients need an advisor who understands these competing priorities and can help bring them into balance.

This recognition reflects the experience our team brings to benefits strategy, plan design, carrier negotiations, compliance and employee communication.

Strategies Tailored to Each Organization

No two employers face exactly the same challenges. Company size, workforce demographics, industry risks, geographic reach and organizational goals can all influence the right benefits strategy.

Our clients receive recommendations developed around their specific needs. We evaluate available data, identify opportunities and help employers consider solutions that align with their budgets and employees’ needs.

Support in a Complex Benefits Environment

Healthcare costs continue to rise while regulations, employee expectations and available benefits solutions continue to change. Employers need more than an annual renewal presentation. They need ongoing guidance from a team that can help them anticipate challenges and evaluate new opportunities.

Our consultants work alongside clients throughout the year to monitor plan performance, navigate compliance responsibilities and respond to emerging workforce needs. We also provide educational opportunities to help employers stay informed. Visit our events page to explore upcoming webinars and programs.

A Focus on Value, Not Just Price

Controlling costs is an important part of every benefits strategy, but the lowest-cost option is not always the best long-term solution. We help clients assess the total value of their programs, including plan performance, employee utilization, administrative efficiency and the ability of benefits to support recruitment and retention.

This approach enables employers to make decisions based on meaningful information rather than price alone.

A Trusted, Long-Term Partnership

Benefits consulting is built on trust. Employers rely on their advisors to provide objective guidance, communicate clearly and advocate for their interests.

The Mployer recognition reinforces our commitment to being a responsive and dependable partner. Our clients can feel confident that they are working with a team recognized for its capabilities, service and dedication to positive outcomes.

Continuing to Raise the Standard

Being named a Top-Rated Benefits Consultant is an important milestone, but it does not change our focus. We will continue to invest in our people, technology and resources so we can bring clients new ideas, better insights and practical strategies.

We are grateful to our clients for placing their trust in Tooher-Ferraris. Their partnership challenges us to keep improving and inspires us to deliver an exceptional experience every day.

If your organization is reviewing its employee benefits strategy or looking for a more proactive consulting relationship, request an employee benefits consultation with the Tooher-Ferraris team.

Picture this: an HR director at a mid-sized manufacturing company reviews the renewal package. The pharmacy line is up 18%. The carrier flags GLP-1 medications as the primary driver. The company added GLP-1 coverage for weight management eighteen months ago because employees asked for it, and because the benefits consultant said it was becoming standard. Nobody designed a clinical access strategy. Nobody integrated it with the wellness program. Nobody established success metrics. The coverage was added as a benefit feature, not as part of a population health strategy. The cost showed up. The outcomes did not.

This scenario is playing out across the mid-market. GLP-1 medications now account for approximately 14% of all US prescription drug spending in 2026, according to HFMA. Among employers who added coverage without a structured clinical framework, the cost trajectory has been difficult to justify at renewal. Among employers who integrated GLP-1 coverage into a comprehensive wellness strategy, the data looks materially different.

Why Coverage Without Strategy Produces the Wrong Outcome

GLP-1 medications are clinically effective. The evidence on weight reduction, glycemic control, cardiovascular risk reduction, and kidney health outcomes is robust and expanding. The problem is not the drug. The problem is that a prescription benefit, in isolation, does not produce population health outcomes. It produces prescription fills.

Obesity contributes to more than 60 chronic conditions and results in 66% higher annual healthcare costs for affected individuals, according to research cited by SHRM. Addressing obesity at the population level, which GLP-1 coverage theoretically enables, requires sustained clinical support, behavioral change infrastructure, and ongoing monitoring. An employee who fills an Ozempic prescription but has no access to nutritional counseling, no integration with a weight management program, and no clinical follow-up is likely to discontinue the medication within six months. The research on GLP-1 discontinuation rates is consistent: without structured support, most patients stop taking the medication before reaching clinically meaningful outcomes, and the costs of the prescriptions they did fill generate no long-term savings.

What a GLP-1 Wellness Strategy Actually Requires

The employers producing favorable GLP-1 outcomes have built three things that employers who simply added the pharmacy benefit have not.

Clinical access criteria tied to population health goals: Access to GLP-1 coverage for weight management should be tied to documented clinical criteria, BMI thresholds, comorbidity presence, or a combination, rather than open to any employee who requests a prescription. Clinical criteria serve two purposes: they direct coverage to the employees most likely to benefit from GLP-1 therapy and least likely to discontinue, and they reduce the actuarial cost of the benefit by focusing utilization on the highest-need population. A well-designed access policy also requires initial evaluation by a primary care physician or endocrinologist, establishing the clinical relationship that ongoing monitoring depends on.

Integration with a weight management and disease management program: A GLP-1 prescription without behavioral support is a pharmacological intervention without the behavioral change infrastructure that determines whether weight loss is sustained. Employers who have integrated GLP-1 coverage with structured weight management programs, including nutritional counseling, activity goals, and regular clinical check-ins, report significantly better adherence rates and outcomes than those who offered the drug as a standalone pharmacy benefit. The population health management services at Tooher-Ferraris help employers design and deploy these support structures as a coordinated extension of the health plan, not as a separate wellness program that competes with it.

PBM contract alignment and rebate optimization: GLP-1 medications carry significant list prices. Brand-name drugs approved for weight management can cost more than $1,000 per month per patient without rebates or negotiated discounts. The net cost to the employer is substantially determined by PBM contract terms: rebate pass-through rates, formulary positioning of specific agents, and step therapy requirements that prioritize lower-cost alternatives within the therapeutic class where clinically appropriate. Employers whose PBM contracts were written before GLP-1 medications represented a significant portion of pharmacy spend may be operating under terms that do not reflect current market dynamics for this drug class.

How to Measure Whether the Investment Is Working

The renewal conversation about GLP-1 costs is easier to manage when the employer has outcome data to present alongside the cost data. Three metrics are most useful in building the case that GLP-1 coverage is generating value.

Total cost of care trend for GLP-1 users versus non-users, measured over rolling 12-month periods, is the primary metric. This requires integrating medical and pharmacy claims data, a step that many mid-sized employers have not taken. An employer who tracks only pharmacy claims sees the cost without the offset.. An employer who tracks total cost of care for GLP-1 users is seeing the full financial picture of what the coverage is actually producing.

Chronic condition prevalence trends within the GLP-1-covered population, tracked annually, show whether the medication is achieving its intended clinical purpose of reducing obesity-related comorbidities. A decrease in diagnosed hypertension, pre-diabetes, or sleep apnea diagnoses within the GLP-1 user population is evidence of downstream medical cost reduction.

Discontinuation rates can reveal where clinical support infrastructure is falling short. High early discontinuation, particularly before clinical outcomes are achieved, may indicate that access to the medication is not being matched by the behavioral support needed to produce sustained results. Discontinuation data points directly to the program design intervention that will improve both clinical outcomes and cost efficiency.

Tooher-Ferraris works with employers to integrate GLP-1 coverage with wellness program design, population health management, and PBM contract strategy. Learn more at https://toofer.com/wellness-and-population-health-management/ and https://toofer.com/pharmacy-management/.

Ready to build a GLP-1 wellness strategy that produces outcomes alongside coverage? The team at Tooher-Ferraris has been helping employers design population health programs since 1932. Contact us today to schedule a no-obligation consultation — https://toofer.com/contact-us/

Frequently Asked Questions

Why does GLP-1 coverage cost more for some employers than others?

The cost difference is driven primarily by three factors: the breadth of access criteria (open access versus clinically restricted access), the presence or absence of integrated behavioral support programs that improve adherence and outcomes, and PBM contract terms that determine the net cost of the drug after rebates and discounts. Employers with narrow clinical criteria, strong support programs, and competitive PBM contracts consistently report lower per-member GLP-1 costs than those without these elements.

What clinical criteria should employers use for GLP-1 coverage?

Most employers tie GLP-1 coverage for weight management to a BMI threshold of 30 or above, or a BMI of 27 or above with a qualifying comorbidity such as type 2 diabetes, hypertension, or sleep apnea. Some employers also require documented failure of a structured diet and exercise program before approving GLP-1 therapy for weight management. These criteria align with FDA labeling and focus coverage on the population most likely to achieve clinically meaningful outcomes.

How do you measure the ROI of GLP-1 coverage in an employer health plan?

The most meaningful ROI metric is total cost of care trend for GLP-1 users compared to a matched control group of non-users, measured over 12 to 18 months. Aon’s research across 192,000 GLP-1 users found 3% medical cost growth versus 9% for a control group, a gap attributable to reduced utilization for obesity-related conditions. Employers who track only pharmacy costs see the cost side without the medical cost offset that represents the long-term value of the coverage.