Connie Perry
The conversation around the cost and coverage of GLP-1 agonist (or GLP-1s) drugs for weight loss is one we frequently have with our clients. With less than 43% of employers covering these drugs for weight loss and major insurers and State Plans pulling back coverage due to cost, the financial implications are significant. However, the potential benefits of coverage extend beyond weight loss, including delaying or preventing other obesity-related comorbidities such as cardiovascular disease, diabetes, sleep apnea, arthritis, and cancer.
Considering drug insurance coverage for obesity drugs requires a careful evaluation for businesses aiming to support employee health and manage long-term healthcare costs. While these drugs can help offer significant health benefits, you must weigh the financial implications, and ensure proper program support to maximize effectiveness and safety.
What is a GLP-1 agonist Drug?
Initially developed to help treat Type 2 diabetes, GLP-1 (Glucagon-Like Peptide-1) agonists play a crucial role in regulating blood sugar levels. These drugs mimic the GLP-1 hormone, naturally produced in the intestines, which plays several critical roles in blood sugar regulation.
GLP-1 drugs help lower blood sugar and reduce appetite. They increase insulin, slow down how fast the stomach empties and can make users feel full, which helps with weight loss and managing diabetes.
Because of their effectiveness in lowering blood sugar and their impact on weight loss, GLP-1 drugs have gained popularity for treating obesity,
leading to their approval for weight loss by regulatory agencies like the FDA.
Risks and Implications
Side Effects
More than 30% of patients dropped off treatment after the first four weeks of use due to the level of non-tolerance with the medication.
Gastrointestinal symptoms including nausea, vomiting, diarrhea, and constipation, are by far the most common side effects of GLP-1 drugs.
Cost
GLP-1 drugs are very expensive for users without insurance, partially due to their efficacy and increasing demand for medications, with averages costing $700 – $1,400 per month. Currently there are no generics available for GLP-1 medications, and it is unlikely that substantial generics will be available until well into the 2030s.
In 2023, reports found these medications are driving up health care costs for employers by more than $300 per insured worker. Other statistics suggest that coverage of this class for weight loss can represent $14.50 Per Member Per Month.
Fraud / Supply Chain
With the increased popularity and demand, falsified versions of the medications have entered the marketplace. These falsified versions are most often sold and distributed through unregulated outlets, including social media platforms.
Healthcare providers are strongly advised by the
World Health Organization and FDA to procure medicines from authorized sources and exercise caution with secondary suppliers. These fake products lack efficacy, can cause toxic reactions, and are produced under unhygienic conditions by unqualified personnel, potentially containing impurities and bacterial contamination.
Prior Authorization
For organizations, instituting a pre-authorization requirement before blanketly covering weight-loss drugs is critical. It helps ensure the drugs are prescribed judiciously, aligning with the individual’s medical needs and overall treatment plan. This step promotes thoughtful decision-making, preventing unnecessary medication use and potential risks.
Consider the following criteria:
- Participants who qualify as obese based on specific BMI measurements must also have at least one additional, related health condition
- Participants are required to commit to essential lifestyle and behavior changes to receive the medication
- Participants commit to a structured weight management program, which includes behavior management coaching and nutrition counseling
- Quantity limits and day supply limits be instituted
The Reality of the Need
As organizations deliberate on coverage options for their employees, the ongoing debate surrounding GLP-1s presents a critical juncture. Diabetes, a prevalent chronic condition, demands attention due to its potential for disease progression and associated healthcare costs, including complications and co-morbidities.
Contrastingly, obesity, historically viewed as a lifestyle issue, has often been excluded from pharmacy benefit coverage by many plan sponsors. However, the rise of GLP-1s has prompted a reevaluation of this stance. The high cost of these medications complicates decision-making for employers, necessitating a balanced approach.
In this complex landscape, it’s vital for organizations to consider their employees’ well-being thoughtfully. Trusting the expertise of healthcare providers is paramount in navigating coverage decisions, ensuring that those genuinely in need of weight management support receive appropriate coverage and care.
Key Takeaways
The landscape of GLP-1s for weight management is evolving rapidly, prompting employers to reassess their strategies for obesity in the years ahead. Confronting the obesity epidemic is a long-term challenge that necessitates substantial cost and societal shifts. It will not happen without significant cost and social change. Considering drug insurance coverage for obesity drugs requires a thoughtful balance between potential health advantages and financial considerations.