Weighing GLP-1 coverage

This story was previously published online on Oct, 11, 2024.

At a high-profile hearing of the Senate Committee on Health, Education, Labor and Pensions in September, Sen. Bernie Sanders, I-Vt., the committee’s chair, said he had commitment from the largest PBMs that they wouldn’t limit coverage if prices for the drug were lowered by
pharmaceutical companies.

However, putting GLP-1s on PBM national formularies doesn’t necessarily translate into coverage, which ultimately is up to health plans and, in the case of self-insured employers, the employers themselves.

Coverage of the GLP-1s for type 2 diabetes hasn’t particularly fazed payers, but as the evidence of their efficacy for weight loss came in — leading first to widespread off-label use when semaglutide and tirzepatide were approved only for diabetes and then to FDA approval for obesity — both the demand and costs soared. Zepbound is available for a list price of $1,059.87 a month, which is approximately 20% less than the list price of Wegovy.

Obesity is a causative factor of a wide range of illnesses (e.g., heart disease, stroke and arthritis) that can result in a cascade of costly pharmaceutical and medical treatments. Logically, the antiobesity effects of the GLP-1s should yield savings from avoided illness and treatment for it. In other words, there should be something like a return on investment for the payers whose budgets are being slammed by an onslaught of GLP-1 prescriptions.

So far, though, the jury is still out on that return, both how large it might be and how long it might take a payer to reap the benefits of slimmer, healthier members.

On national formularies but…

Formulary Watch, a Managed Healthcare Executive publication, contacted the three largest PBMs — CVS Caremark, Express Scripts and Optum Rx — and Prime Therapeutics about which GLP-1s are on their national formularies. The information they shared showed that the PBMs have the weight loss drugs, including Wegovy and Zepbound, on their national formularies (see the table on page 18), but they also recommend prior authorization and other
utilization management efforts that may limit access. The PBMs also recommend optional lifestyle management programs.

However, the gap between formulary inclusion and actual coverage was apparent in the results of the KFF’s annual survey of employer health benefits, which was published in October. The survey,which included more than 2,100 nonfederal private and public employers, showed that just 18% of employers with 200 or more employees cover GLP-1 agonists when used for weight loss. Of those that do provide coverage, according to the KFF results, 24% require employees to meet with a dietitian or other professional, 8% require employees to enroll in a lifestyle or weight loss program before approving a GLP-1, and 10% require employees to enroll in a lifestyle or weight loss program while taking these drugs.

David Lassen

For coverage to increase, prices will have to come down, but there must also be proven outcomes, says David Lassen, chief clinical officer at Prime Therapeutics. “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 — be back to baseline weight and cardiometabolic levels.”

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

Half of people taking GLP-1s for weight loss are covered by commercial insurance, according to Real Chemistry, a healthcare analytics and communications company. Approximately 82% of claims for a GLP-1 drug are ultimately approved, according to Real Chemistry’s IRIS database. Real Chemistry launched IRIS in April 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 the plan. The IRIS data show that the most common comorbidities of people taking a GLP-1 drug for weight loss are hypertension, type 2 diabetes, hyperlipidemia and sleep apnea.

The PBMs that Formulary Watch contacted said they are working to lower the cost of weight loss medications for clients with programs designed to encourage appropriate use and support members. They also said they are negotiating with drug manufacturers for lower prices. All provide some type of lifestyle management program, and the cost of the GLP-1s came up often.

“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 says.

On different tiers

About 20% of Prime Therapeutics’ covered lives are in a benefit plan that covers weight loss, Lassen said. Prime Therapeutics provides the same coverage for Wegovy and Zepbound for weight loss in a tier 3 or tier 4 position.PBMs organize their formularies into tiers, and drugs in higher tiers have higher copays. Generally, therapies listed in tier 4 are high-cost or specialty drug, and patients may pay a percentage of the total drug cost.

CVS Caremark officials say most of the people covered by its drug management plans have coverage for obesity medications — which include Saxenda (liraglutide), Qsymia (phentermine and topiramate), Wegovy and Zepbound — in a preferred tier 2 position and that it 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 compared with clients who did not adopt the program, as well as six times the total weight loss for members previously struggling to lose weight on medication alone.

Cigna Healthcare’s standard three-tier prescription drug list includes Saxenda, Wegovy and Zepbound as tier 2 products, as well as Contrave (naltrexone and bupropion), Imcivree (setmelanotide) and Qsymia, but indicates that this is optional coverage. Cigna recommends prior authorization and quantity limits. Earlier this year, Evernorth, the health services division of Cigna that includes its PBM, Express Scripts, introduced a financial guarantee for clients interested in covering GLP-1 therapies, called EncircleRX. The company pitched the program as giving 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. In January, Optum Rx launched Weight Engage, a weight management and wellness support program. 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.

The number of prescriptions and costs for GLP-1 drugs are expected to increase, especially as more data become available about how these drugs affect metabolism and the cardiovascular system. Study after study shows that GLP-1 drugs help reduce a myriad of downstream effects of obesity. Novo Nordisk A/S, 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 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. And it is not just industry-sponsored studies that are pointing in this direction. In March, the FDA added an important cardiovascular disease prevention indication to Wegovy for adults with signs of cardiovascular disease and either obesity or overweight.

Sanjula Jain, Ph.D.

The impact on the healthcare system could be huge if costs are saved from a healthier population of people who are avoiding comorbidities. “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?” asks Sanjula Jain, Ph.D., senior vice president of market strategy and chief research officer at Trilliant Health.

In a new analysis, Trilliant looked at the data on GLP-1 use in patients with diabetes. “We’ve seen in our study that, on average, [people with diabetes] are on more prescriptions today than they were previously,” Jain said. “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’ll] see some value there.”

Rita Glaze-Rowe, president of transformative healthcare markets at Real Chemistry, says employers need to think about coverage of GLP-1 as something more than just cost: “They need to see this as an investment in their workforces and ask: What is going to help my workforce 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 to get there.”

Rita Glaze-Rowe

Glaze-Rowe’s colleague at Real Chemistry, Leslie Isenegger, M.P.P., practice leader of corporate pricing and public affairs, says a broad view is needed. “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 says.

The way Isenegger sees it, the GLP-1s could lower overall costs.

“The GLP-1s are a space where we are seeing the potential to change spending in the medical benefit by spending more in the pharmacy benefit,” she says. “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.”