With an average monthly cost of $1.2K – 1.5K, brokers and employers must evaluate coverage options and strategies to manage runaway costs related to GLP-1s for weight loss.
What are GLP-1s?
GLP-1s, or glucagon-like peptide-1 receptor agonists, are a class of medications initially developed to treat type 2 diabetes. These drugs mimic the action of the GLP-1 hormone, which is naturally produced in the gut. GLP-1 plays a crucial role in regulating blood sugar levels by stimulating insulin secretion, inhibiting glucagon release, and slowing gastric emptying.
How are they used for weight loss?
Although GLP-1s were initially used for diabetes management, their impact on appetite and food intake has led to their use as weight loss medications.
What is the role of a Pharmacy Benefit Manager in managing GLP-1s?
When managing GLP-1s, a PBM should ensure the following:
- Effective Clinical Criteria: Implement robust clinical criteria to ensure appropriate use of GLP-1 medications.
- Short Authorizations: Facilitate appropriate authorization processes to ensure timely access to necessary medications.
- Alternative Non-Pharmacotherapeutics: Present solutions other than medications, such as behavioral modifications and lifestyle interventions.
- Active Monitoring: Continuously monitor the effectiveness and safety of weight loss treatments.
- Engage with Providers and Members: Work closely with healthcare providers and plan members to ensure coordinated care and support.
Additionally, your PBM should promote:
- Behavioral Modifications: Encourage changes in behavior to support healthy weight loss.
- Lifestyle, Diet, and Exercise Changes: Advocate for comprehensive lifestyle changes, including diet and exercise, to enhance the effectiveness of GLP-1 treatments.
What is the Coverage Approach PBMs are Taking?
- Conservative Approach:
Exclusion of Coverage: Some clients opt to exclude coverage for GLP-1s entirely, avoiding the high costs associated with these medications. - Moderate Approach:
Variable Coverage: This approach involves selective coverage based on specific criteria, such as patient eligibility, clinical necessity, and cost-effectiveness. Coverage may be provided for certain cases while others may be excluded. - Comprehensive Approach:
Investment in Positive Outcomes: Clients taking this approach invest in the potential long-term benefits of weight loss associated with GLP-1s. They cover these medications to potentially reduce overall health risks and associated healthcare costs, recognizing the positive impact on patients' health and well-being.
Key Takeaways
Your PBM should be working with you and each individual group to align goals and strategies in order to meet the needs of the plan and its members while still containing costs.
The right PBM partner:
- Utilizes rigorous clinical expertise and sound formulary management
- Provides flexibility to align with client clinical and financial goals
- Continuously monitors the demand, accessibility, cost and utilization of GLP-1s for weight loss
Understanding the various coverage options and market trends is crucial for employers and brokers to manage demand, accessibility, cost, and utilization of these medications effectively.
If you would like to discuss PBD's cost contained approach to the management of GLP-1s for weight loss, please reach out. We're here to help!