10/3/2023 | Expert Insight

Author: Amy Beal, PharmD, Pharmacy Services Director 

If it doesn’t have one already, your health plan needs a GLP-1 strategy.

Use of Ozempic^®, a GLP-1 medication approved by the Food and Drug Administration (FDA) to treat diabetes, is increasing 75% (or $6.7 billion in spending) on a rolling 12-month average.^[1] This type of snowballing drug spend, if left unchecked, can cause plan premiums to soar, potentially pricing out members, leaving people who need drug coverage without the ability to pay for it. To help, Pharmacy Benefits Managers (PBMs) should have options to curb spending for their clients, particularly on medications for which lower-cost alternatives are readily available.

Much of Ozempic’s increased utilization has nothing to do with diabetes, but with weight loss, something Ozempic is not FDA approved to treat. For example, from 2018 to 2021 the share of Ozempic users with a diabetes diagnosis decreased by 16%. During the same timeframe the share of Ozempic users who were overweight but did not have diabetes increased by 225%.^[2] The public perception of Ozempic as a magic weight loss cure is responsible for this increase, and is both untenably expensive, and medically inaccurate.

To combat this rise in off-label use of Ozempic, we have devised five tactics health plan payers can deploy to keep GLP-1 utilization increases under 20% year-over-year.

The first and most obvious strategy.

Health plans can have their PBMs remove Ozempic from their covered drug lists. Ozempic’s word-of-mouth popularity, media hype, and brand-name recognition helps drive its utilization and increases a health plan’s overall GLP-1 utilization. Ozempic, however, isn’t the only GLP-1 on the market. Trulicity^® , for example, is a GLP-1 that is FDA approved to treat diabetes. During the same timeframe during which Ozempic utilization increased by 75%, Trulicity utilization increased only 25%.^[3]

Making a coverage change to a less utilized GLP-1 can rapidly decrease utilization for health plans that are facing unsustainable increases in GLP-1 usage, while preserving options for members who need GLP-1s to remain healthy.

A second, simple step.

Health plans could ask their PBM to place a preauthorization on any GLP-1s they decide to cover. Preauthorization fosters appropriate utilization and should be online and easy for doctors, who would need to confirm their patient has diabetes. Once the PBM receives the preauthorization request, its pharmacists can evaluate it for accuracy and then approve coverage for diabetes patients. If the PBM does not have enough information about the patient’s condition, it can follow up with the prescribing doctor to ensure the physician is prescribing the drug for diabetes, not weight loss. While this strategy removes a tool that a doctor might use to treat weight loss in a patient, for some health plans, this may be the best way of keeping GLP-1s available to members with more serious conditions, while keeping premiums low enough that members can afford them.

Third: have an alternate medical solution for overweight people.

Weight loss is a serious medical matter for many patients, and therefore a medical solution is needed. Currently, public perception has led to GLP-1s being requested as that solution.

But the fact is, when people stop taking GLP-1s for weight loss, they can gain the weight back and their improvements in blood pressure, blood sugar, and cholesterol values can also reverse. According to a 2022 study in the journal Diabetes, Obesity and Metabolism that followed 327 people after they quit taking semaglutide (the generic name of Ozempic) injections, “ongoing treatment is required to maintain improvements in weight or health.”^[4] In other words, these are drugs that people will need to take for their lifetime in order to maintain successful results. Accordingly, health plans will be paying around $12,000 per person, per year (assuming current pricing) to keep people on GLP-1s. Otherwise they face reversing any health benefits originally gained by covering GLP-1s for weight loss in the first place. For some health plans, that kind of cost might be sustainable, but for others, particularly smaller ones that rely on low per member per year costs to keep premiums low, it might be crippling. Therefore, health plans can consider removing GLP-1 coverage for weight loss while covering other, less expensive options.

Many health plans have historically been leery about covering one of many procedures which fall under the heading of “bariatric surgery,” but these services are often available for one-time fees of $10,000 to $15,000 (about the cost of one year of Ozempic). According to the Cleveland Clinic, “Weight loss surgery is considered successful if you lose 50% of your excess weight and keep it off. By this standard, the success rate is 90%. Many people experience steady weight loss for the first two years, then stall or regain some weight after that. Usually, the weight regained is less than 25%.”^[5] Losing 25-50% of excess weight over a sustained period of time results in far more net weight loss than that experienced under the GLP-1 rebound.

Plans might also consider coverage of cheaper, non-GLP-1 medications which are FDA approved for weight loss, to give members access to necessary care at a cost that isn’t prohibitive.

Active Fraud, Waste, and Abuse (FWA) monitoring is a fourth key to controlling GLP-1 costs.

Between Jan. 1, 2022 and April 24, 2023 Scripius (approximately 1 million members) identified $6.1 million in GLP-1 claims that had the potential for FWA. These were pharmacy claims for GLP-1s where the patient had no medical claims indicating they had diabetes or even prediabetes. Many of these prescription claims were written by doctors living many states away from their patients. For example, members in Southeastern Idaho often received GLP-1 prescriptions from doctors in Orange County, California.

PBMs should wrap their arms tightly around FWA in the GLP-1 class to safeguard their members’ health, and to keep member premiums from skyrocketing due to fraudulent prescriptions. Teams should be able to investigate and identify doctors who are scamming the system by prescribing GLP-1s for weight loss (even across state lines) and provide appropriate accountability for false claims, off-label prescriptions, and made-up diagnoses.

Fifth and finally, PBM’s should create easier access to non-GLP-1 diabetes therapies.

Farxiga^® and Jardiance^®, known as SGLT2 inhibitors, are important treatments for people with Type 2 Diabetes Mellitus (T2DM). These drugs have also demonstrated beneficial effects for people with heart failure and chronic kidney disease with or without a T2DM diagnosis. To provide better access to these products, PBMs should remove step therapy requirements from both drugs so patients and prescribers have easier access and increase use of SGLT2 therapies, which are generally less expensive but efficacious.

Achieving a 18% year-over-year growth rate for GLP-1s is possible.

Using the strategies above, Scripius and its health plan partners achieved a year-over-year growth rate in GLP-1 utilization of 18% in 2023.^[6] Curbing utilization growth in the GLP-1 category will be one key strategy for health plan payers to keep plan costs and premiums as low as possible.

Looking ahead, as more GLP-1 manufacturers seek and obtain FDA approval to use GLP-1s for weight loss (Wegovy^® and Saxenda^® have this approval now), health plan payers should consult with their PBM about whether weight loss coverage is a good idea. Health plan payers should know the long-term costs of coverage (and denial of coverage) and how those decisions will impact their business, their health plan, and the lives of their members.

With available corporate wellness programs and other medical options to treat obesity, weight loss coverage for GLP-1s is an issue health plan payers should consider in light of all available information. If you would like to consult with our team about coverage for your health plan, please email us at GetSavingsNow@Scripius.org. You can read more Industry Insight on our webpage at Scripius.org/industry-insight.