Are PBMs Putting Obesity Drugs on Formulary?

Pharmacy benefit managers (PBMs) and the trade organization for the largest of them, the Pharmaceutical Care Management Association, have assured Congress and the public that they are committed to providing coverage for the glucagon-like peptide 1 (GLP-1) receptor agonist drugs. This much-talked-about class of drugs includes semaglutide (Ozempic for diabetes and Wegovy for weight loss) and tirzepatide (Mounjaro for diabetes and Zepbound for weight loss.)

Last month at a hearing of the U.S. Senate Committee on Health, Education, Labor, and Pensions, committee chair Senator Bernie Sanders (I, Vt.) said he had commitment from the largest PBMs not to limit coverage if prices for the drug were lowered by pharmaceutical companies.

But putting GLP-1s on PBM national formularies doesn’t necessarily translate into coverage. The high price of GLP-1s is one factor in coverage decisions for the obesity indications. Zepbound is available for a list price of $1,059.87 a month, which is about 20% lower than Wegovy. But another consideration by plans and employers is whether drugs such as Wegovy and Zepbound enable patients to be healthier, which would lower the overall costs of healthcare.

In other words, is there a return on investment for covering high-cost weight loss products? So far, the jury is still out on that, but data continue to be released about potential health benefits of these drugs.

Formulary Watch wanted to assess the PBM formularies for inclusion of GLP-1 drugs for obesity. We reached out to largest PBMs (CVS Caremark, Express Scripts, Optum Rx and Prime Therapeutics) for information about which products are on their national formularies and the tiering and utilization management these products were subject to, as well as the lifestyle managements services that are available or may be required.

What we found was that these PBMs provide formulary inclusion for many of the weight loss drugs, including Wegovy and Zepbound, at the national level. (See Table below.) We also found that all of these PBM recommend prior authorization and other utilization management. The PBMs also provide an optional lifestyle management programs.

Although the national formularies created by the PBMs hold considerable sway over the drugs that health insurers and self-employed employers, they are also free to deviate from those formularies.

KFF published the results of its annual survey of employer health benefits this week. It found that just 18% of companies with 200 or more employees cover GLP-1 agonists when used for weight loss. Of those companies that do provide coverage, 24% require employees to meet with a dietitian or other professional. About 8% require employees to enroll in a lifestyle or weight loss program before approving a GLP-1 and 10% require employees to enroll in lifestyle or weight loss program while taking these drugs.

David Lassen

For coverage to increase, prices will have to come down, but there also has to be proven outcomes, David Lassen, chief clinical officer at Prime Therapeutics, said in an interview. “There should be a positive return on that investment, meaning the drugs are effective. People will lose weight, but we know that 80% of them will in two years if they do not persist, they are back to baseline weight and cardiometabolic levels.”

In fact, just-released data from Prime Therapeutics show poor two-year persistence with 1 in 6 members who are adherent, as compared with three-year clinical trial data of greater than 85%.

Coverage Landscrape

Half of patients taking GLP-1 for weight loss are covered by commercial insurance, according to Real Chemistry, which provides marketing communications for the healthcare sector. About 82% of claims for a GLP-1 drug are ultimately approved, according to Real Chemistry’s IRIS database. Real Chemistry launched IRIS in April 2024 as a dashboard to provide insights into the obesity and GLP-1 market.

The top reasons for insurance rejection of these claims are missing information, prior authorization required, and the product is not covered by plan. The IRIS data has found that of patients taking a GLP-1 drug for weight loss, the most common comorbidities are hypertension, type 2 diabetes, hyperlipidemia and objective sleep apnea.

The PBMs that we contacted said that plan sponsors are the decision-makers regarding GLP-1 coverage for members, including setting out-of-pocket costs. They said they are working to lower the cost of weight loss medications through the appropriate use, clinical programs to support members, and negotiating with drug manufacturers. All provide some type of lifestyle management program.

The PBMs we contacted indicate the reason for non-coverage of GLP-1 drugs for obesity is due to cost. “It would all come down to these being cost prohibitive, and there are concerns related to whether there will be a return on that investment,” Lassen said.

Prime Therapeutics provides parity coverage for Wegovy and Zepbound for weight loss in a tier 3 or tier 4 position. About 20% of covered lives are in a benefit plan that covers weight loss, Lassen said.

At CVS Caremark, a majority of employer lives in its book-of-business have coverage for obesity medications, which include Saxenda, Qsymia, Wegovy and Zepbound, in a preferred tier 2 position and recommends prior authorization. CVS Caremark offers the CVS Weight Management program, which is a combination of registered dieticians, board-certified endocrinologists and virtual care. The program is offered to members regardless of whether they are taking a weight loss medication.

A CVS spokesperson said the use of the weight management program has resulted in 22% less client spend on GLP-1s for weight loss vs. clients who did not adopt the program, as well as six times total weight loss for members previously struggling to lose weight on medication alone.

Cigna Healthcare’s standard 3-tier prescription drug list includes Saxenda, Wegovy and Zepbound as tier 2 products and Contrave, Imcivree, Qsysmia, but indicates this is optional coverage. Cigna recommends prior authorization and quantity limits. Evernorth in March 2024 introduced a financial guarantee for clients interested in covering GLP-1s therapies called EncircleRx. The program aims to give employers and health plans greater predictability and control of their GLP-1 spend.

Optum Rx puts Wegovy, Zepbound, Saxenda and Qsymia in the tier 2 position and recommends prior authorization and quantity limits. Optum Rx launched Weight Engage, a weight management and wellness support program, in January 2024. Customers have the flexibility to configure Weight Engage elements, and consumers may access different components of the program using a live coach or going through a digital platform.

Employer Influence on Coverage

The number prescriptions and costs for GLP-1 products are expected to increase, especially as more data becomes available about how these drugs impact the metabolic system. Data is beginning to show that GLP-1 drugs help to reduce the risk factors associated with obesity.

In March 2024, the approved Wegovy to reduce the risk of cardiovascular death, heart attack and stroke in adults with cardiovascular disease and either obesity or overweight. Novo Nordisk USA, the manufacturer of Wegovy, released the results of a study that showed semaglutide reduced kidney disease progression, major cardiovascular side effects and death by 24%. Eli Lilly and Company, the manufacturer of Zepbound, announced data in April 2024 from a phase 3 trial showing that tirzepatide reduced sleep apnea severity by up to almost two-thirds in those with obstructive sleep apnea and obesity.

The impact on the healthcare system could be huge if costs are saved from a heathier population of people who are avoiding comorbidities. Unfortunately, there isn’t enough data to have a clear picture yet of what that looks like.

Sanjula Jain

“Data are becoming available about the clinical benefits of GLP-1 therapies but what is the net cumulative impact on outcomes and total cost of care,” Sanjula Jain, senior vice president of market strategy and chief research officer at Trilliant Health, asked in an interview. 

In a new analysis, Trilliant looked at the data of GLP-1 use in patients with diabetes. “We’ve seen in our study that, on average, diabetics are on more prescriptions today than they were previously. So that suggests more of an additive effect, so it's more cost. It’s also not necessarily reducing the number of prescriptions that patients are on. Is that enough clinical value to justify that cost? Maybe over time we see some value there.”

Rita Glaze-Rowe, president of transformative health at Real Chemistry, said employers need to think about coverage of GLP-1 as cost versus value. “They need to see this as an investment in their workforces and ask: what is going to help my workforces be healthier and more productive. They have to be looking at how they need to structure their benefit design over the longer term to be holistic, and there is actual, real value generated by that. This turns a cost argument into an investment argument. We have to start collecting the data in order to get there.”

To solve the problem of pricing and access for prescription weight loss drugs, everyone needs to be in a room together, Leslie Isenegger, practice leader of corporate pricing and public affairs at Real Chemistry, said in an interview. “When thinking about new technologies that are coming to the fore with pharmaceutical innovation, we have to ask, how do we need to think about access differently across the entire healthcare spectrum?,” she asked

The GLP-1 therapies have the potential to lower costs overall, she said. “The GLP-1s is a space where we are seeing the potential to change spending in the medical benefit by spending more in the pharmacy benefit,” she said. “We are having the conversations about the price of the medicine. But we’re not having a holistic conversation about downstream costs that are saved from a heathier population who are avoiding comorbidities.”