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Education and Recommendations on Weight Loss Spend

Glucagon-like peptide 1 (GLP-1s) are a class of medications used to treat diabetes that can also lead to weight loss. In 2021 and 2022, GLP-1s have been in high demand, surpassing insulins as the top drug for spend in the antidiabetic class. Additionally, they became a notable driver of non-specialty and overall prescription drug trend. Some notable products in this class of drugs include injectable semaglutide (Ozempic), oral semaglutide (Rybelsus), injectable dulaglutide (Trulicity), injectable terzepatide (Mounjaro) or injectable liraglutide (Victoza) for diabetes and injectable semaglutide (Wegovy) or injectable liraglutide (Saxenda) for weight loss.

Potential Factors Driving Demand for GLP-1s

Pharmaceutical Innovation

Advancements in drug formulations and research can affect the demand for GLP-1s.

  • The newest versions of GLP-1s have the benefit and appeal of being administered just once weekly compared to older versions that require daily administration.
  • When used at the lower diabetes dosing, newer branded antidiabetic formulations may be less costly than the weight loss formulations.
  • Older generic and inexpensive obesity products typically demonstrate weight loss of 5% to 10%. Whereas newer branded and more expensive anti-obesity products typically demonstrate weight loss of 10% to 15%. The newest formulation pending FDA approval may even see up to 20% weight loss.
  • GLP-1s are part of recent treatment guidelines by the American Diabetes Association as first-line therapy when there are high cardiovascular risk factors.

Prescribers

GLP-1s have received great acceptance and appeal amongst the prescriber community even though, as with any medications, there are always risk-to-benefit considerations.

  • Prescribers appear to be comfortable using diabetes products for off-label purposes such as weight loss but at the doses approved for the diabetes indication(s).
  • There is a strong desire for healthcare professionals to prescribe medications for weight loss in response to the obesity epidemic, which is a major contributor to some of the leading causes of death in the U.S., including heart disease, stroke, diabetes, and some types of cancer.
  • Prescribers find and take the path of least resistance. The progression of claims activity suggests prescribers may try ordering the older generic weight loss medications first. If these medications are not approved, they may try more expensive weight loss medications. If both weight loss medications are rejected at the point of sale, then they will prescribe a diabetes medication. Therefore, the prescriber may avoid potential conflict with the patient and avoid the hassle of utilization management requirements by finding an alternative medication.

Plan Design

Generally, pharmacy benefit plans opt to restrict the use of weight loss formulations to certain populations or exclude them altogether while leaving access relatively unrestricted for diabetes formulations.

  • Many plans may have insufficient member cost shares to mitigate the influence of copay card incentives for GLP-1 products. With little to no out-of-pocket costs, financial deterrents may be mitigated and lead to higher demand. In the case of the GLP-1s, copay card values may cover $150 to $200 per month (almost 20% of the cost) with consumers paying as little as $25 per month.
  • Obstacles such as lack of coverage or prior authorization for weight loss products appear to be creating a demand for the diabetes formulations that may not otherwise have been present.

National CooperativeRx Recommendations

One of the value-added services National CooperativeRx provides to its member-owner groups and broker/consultant partners is the monitoring of market dynamics and ongoing re-evaluation of clinical and plan design strategies. Historically, the coverage of weight loss medications with utilization management has been our recommendation. After all, plan sponsors are going to pay for the health complications associated with excessive weight. A comprehensive and aligned strategy to improve the overall health of participants is needed. In general, while acceptance of National CooperativeRx’s recommendations is typically high with adoption rates of 90%+, coverage of weight loss products has been an exception. Only about 25% of National CooperativeRx groups cover weight loss and, of these, about 50% do so with prior authorization. Due to evolving market dynamics, the historic recommendations have been revised.

In summary, recommendations for plan sponsors to consider may include:

  • Re-evaluation of member cost shares
    • Meet or exceed copay card values
    • Incentivize generic options/discourage brand options
  • Re-examination of plan coverage and exclusions
    • Work to develop your organization’s philosophy and clarify intent to develop a comprehensive strategy to improve health and mitigate costs
  • Opt into National CooperativeRx Clinical Programs
    • High-Cost Claims Review helps provide some immediate oversight
    • Advanced Utilization Management provides infrastructure for possible future management

The National CooperativeRx team is readily available to analyze and discuss the best practices for each of our member groups. Please reach out to your strategic account executive if you are interested in reviewing your member groups’ plan design.

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