April 18, 2023

Over the past few months, news headlines have highlighted the rapid growth in popularity and usage of GLP-1 agonists, medications approved by the Food and Drug Administration (FDA) to treat type 2 diabetes and obesity. Consequently, self-insured employers are grappling with a number of challenges, including appropriate prescribing and use of these medications, drug shortages and rising costs. The following text summarizes major takeaways from a conversation with 70 Business Group employer members, who met virtually to discuss these challenges, as well as solutions.

Employer approaches to coverage for GLP-1s are varied and may be tied to the type of condition the medication is being prescribed for.

When polled, more than half the employers who participated in the call indicated that they cover GLP-1 medications only for members with diabetes; fewer reported that they provide coverage both for diabetes and for obesity. When discussing coverage decisions, one employer indicated that high employee turnover has factored into their decision not to cover GLP-1s to treat obesity; another said that all prescription anti-obesity medications are part of their standard formulary and therefore are covered. The same member has chosen to include these medications on the preventive drug list, offering them at no out-of-pocket cost for members.

Even if an employer doesn’t provide coverage for GLP-1s for the treatment of obesity, employers report that physicians and employees may be creating workarounds. One indicated that the company is seeing increased diabetes claims, and another said that in some cases, doctors might prescribe a patient without diabetes a diabetes drug like metformin before filling a script for a GLP-1 in order to establish a medical history of diabetes, potentially avoiding any edits or prior-authorization (PA) barriers.

Employers are working with a number of partners—often starting with their PBMs—to promote appropriate use and manage costs through PA, step therapy and other approaches.

To get a better understanding of the various tactics available to promote appropriate use and mitigate rising cost trends, most employers on the call shared they are having discussions with multiple existing partners, including:

• PBMs (pharmacy benefit managers);
• Health plans;
• Diabetes solution vendors;
• Weight management solution vendors;
• Consulting firms; and
• Well-being vendors.

One employer shared that its PBM is implementing a "smart PA" edit, which requires all prescriptions for Ozempic, Trulicity, Rybelsus, Victoza or Mounjaro to be subject to a PA if the system does not detect another prescription that could indicate that the member has been treated for diabetes within the past 2 years (e.g., a diabetes-related medication or glucose testing supplies, etc.). On the other hand, if a member does have a record of other, similar prescriptions, PA will not be needed for the GLP-1, and the claim will process automatically without issue. This employer member also has PA in place for medications to treat obesity (i.e., Qsymia, Wegovy, Saxenda). As of January 1, 2023, one employer who covers GLP-1s for diabetes and for weight loss is utilizing step therapy requirements (i.e., protocols that may require a member to attempt a lower cost prescription for treatment before ‘stepping up’ to a more expensive alternative medication) for one of the generics and/or proof of diabetes to minimize off-label usage. Some employers on the call also mentioned that they are evaluating a value-based purchasing contract for these products.

Along with ensuring the appropriate utilization of GLP-1s, several employers on the call are considering how they can better integrate the use of GLP-1s with intensive behavioral interventions. One employer is working with its PBM and diabetes management vendor to approve and reauthorize GLP-1 fills based on engagement with a preventive health program and weight loss results. In addition, another company is leveraging improved criteria for use of weight management GLP-1s by requiring attestation of involvement in a lifestyle modification program. This requirement is a way to ensure that members are making appropriate lifestyle changes along with taking the medication. Another is enhancing its weight management strategy to combine anti-obesity medications with physician, registered dietician and mental health support. This employer is also considering plan design changes that offer reduced coinsurance to members that participate in the program to encourage people to get that support.

Employers are balancing myriad information and factors as they navigate the path forward related to GLP-1s.

Several employers on the call cited a report from the Institute for Clinical and Economic Review (ICER) for insight into the cost effectiveness of GLP-1s for weight loss; the ICER report suggests that GLP-1 costs would need to be reduced by approximately 45% in order to be considered cost effective.

A few employers on the call discussed some of the negative feedback they have received from employees and physicians over their GLP-1 coverage decisions (e.g., PA requirements).

And finally, many employers on the call expressed concerns over the need for sustained lifestyle changes among those taking GLP-1s. Without this crucial component, employees and their family members may not attain long-term benefits from taking these medications.

More Topics

Cost Management Pharmacy Plan Design & Administration Preventive Services