KFF: Large Numbers of People Clinically Eligible for GLP-1 Drugs

About 42% of those with commercial insurance could be eligible for glucagon-like peptide 1 (GLP-1) drugs used to treat people with type 2 diabetes, obesity, or excess weight and weight-related health issues, according to a new KFF analysis. But only about 3% of adults with employer coverage had a prescription in 2022 for these medications.

The Peterson-KFF Health System Tracker estimated the clinical eligibility and use of GLP-1 drugs among adults under age 65 in the private and employer-sponsored insurance. The analysts used the 2023 National Health Interview Survey (NHIS) and Merative MarketScan commercial claims data.

They found that 57.4 million adults under the age of 65 could potentially be eligible for GLP-1 drugs based on currently approved FDA indications of these drugs. This includes 36.2 million people with an obesity diagnosis alone. (See table below.)

Previous analysis from KFF has found that few drugs approved to treat obesity are covered by plans providing covering for through the Affordable Care Act. The GLP-1 drugs have higher costs than older weight loss drugs. Zepbound (tirzepatide) is available for a list price of $1,059.87, which is about 20% lower than Wegovy (semaglutide).

IPD Analytics estimates a per-member-per month cost increase of about $15 for a 1-million-member health plan if 10% of eligible adults take GLP-1 therapies for weight loss. If uptake increased to one-third of eligible adults, the cost could increase to $50.

Already, payers are beginning to see increased costs related to GLP-1 drugs. Navitus, for example, has found that one of the largest impacts on 2023 drug spend is the growth of use GLP-drugs to treat patients with diabetes, but the use of GLP-1s for weight loss was not included in this analysis.

Employers surveyed by Mercer are implementing utilization management strategies such as prior authorization and reauthorization requirements when they do provide coverage for the weight-loss products. Additionally, 60% of those surveyed said they are interested in implementing a program that combines a therapy for weight loss with counseling and nutrition support.

Related: KFF: 1 in 8 Adults have Used GLP-1 Agonists

According to KFF polling from May 2024, 6% of all adults report that they currently are taking a GLP-1 drug, and 12% report that they’ve ever taken a GLP-1 drug. Of those who report taking the GLP-1 drugs, 43% have diabetes, 26% have heart disease and 22% have obesity or overweight (22%).

As more data become available about how GLP-1 drugs impact the metabolic system, demand for and use of GLP-1 drugs are expected to grow. GLP-1 drugs have gained a lot of attention for their ability to help people lose weight but also for their ability to reduce the risk factors associated with obesity.

Wegovy’s approval in March 2024 for a new indication could open the door for more coverage some Medicare beneficiaries. The FDA approved Wegovy to reduce the risk of cardiovascular death, heart attack and stroke in adults with cardiovascular disease and either obesity or overweight.

The approval is based on the SELECT cardiovascular outcomes trial, which demonstrated that Wegovy statistically significantly reduced the risk of major adverse cardiovascular events (MACE) by 20% compared with placebo when added to standard of care.

Additionally, Novo Nordisk USA, the manufacturer of Wegovy, released in March 2024 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.

While coverage of GLP-1 drug is still in flux, plans are beginning to develop to ways to manage these drugs and their costs. Evernorth, for example, 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.

Source: Peterson-KFF Health System Tracker