Will Employers Support Demand for Coverage Expansion of GLP-1 Agonists into Weight Loss?

Image credit: New Africa | stock.adobe.com

Glucagon-like peptide 1 receptor agonists (GLP-1s) have been a staple of the pharmaceutical industry for several decades now—with the first FDA approval of exendin-4 dating back to 2005¹—so one might not be surprised that many employers have been covering these types of drugs (for the treatment of diabetes) for quite some time.

However, new developments in the fields of efficacy, FDA approvals of these drugs in the weight loss class, and greater consumer demand have served as motivating factors for Morgan Company to put together a “Market Perspectives” report¹ on the matter.

With this paper intended for employers, investigators aimed to provide an overlook of the GLP-1s landscape by focusing on three main takeaways:

1. The authors predict that demand for such drugs will remain at high levels, powered by employers seeing the benefit in keeping the coverage, awareness that is powered by the media, and the ability for these drugs to treat multiple conditions.
2. Advanced primary care that is powered by the proper technology are prepared to offer obesity care.
3. Developing strategies for not only sustaining a high quality a care, but tackling demand of these drugs, are serious issues to keep in mind.

GLP-1s were designed to replicate the effects of glucagon-like peptide-1, which is a hormone that boosts insulin secretion, suppresses the release of glucagon, and enacts a feeling of satiety. These medications are known for assisting with glycemic control, lowering post-meal blood sugar spikes that could occur, and with the curbing of the appetite, offer weight loss capabilities.

When it comes to treating diabetes, the hormones help increase glycemic control, lower HbA1c levels, and lessen the risk of cardiovascular episodes. Although some of these medications have proven to be effective in helping individuals lose weight, there are not yet enough results to fully support these claims. Instead, the medications are recommended as an adjunct therapy in combination with both a reduced-calorie diet and increased physical activity; they are to be used by individuals with obesity, or who are overweight with one weight-related comorbidity, such as hypertension or type 2 diabetes.

One example of this debate comes directly from Eli Lilly and Company, who in a letter to the public, warned against the use of its drugs for cosmetic weight loss.² The company noted that neither Mounjaro or Zepbound are designated for cosmetic use, but rather are intended to treat serious diseases, with Mounjaro for type 2 diabetes and Zepbound for obesity in specific body mass index (BMI) ranges of a BMI of 30 kg/m² or greater, or those who are overweight with a BMI ≥ 27 kg/m² or greater.

As previously stated, the authors also pointed to these drugs’ presence in the news cycle as a challenge when developing policies on how GLP-1s should be covered. There have also been debates on the possibility of prescribing for obesity as a chronic condition. As a result, employers must determine whether they will be authorizing for a continuous period or only a limited period of time, which at that point, would mean patients would have to stop taking those drugs or pay for the cost out-of-pocket. On average, the list prices are $1000 per month.

Alternatively, as a way to not only manage costs but provide access to these treatments, some employers have been wording their coverage rules so that access to GLP-1s is granted only when all other alternative treatment options (such as other drugs classes) have been considered, or when plan members participated in lower-cost fitness, nutrition, or behavioral programs.

Overall, the authors suggest a reconsideration of the current obesity care paradigm. In order for GLP-1s to be successful, the importance of patients having support from a provider who fully understands their personal situation is paramount, which primary care has the potential to accomplish.

Looking ahead, “employer-initiated outcomes-based contracting in the pharmaceutical market remains scarce. Among obesity management vendors however, we are seeing companies that incorporate pharmacotherapy into treatment protocols putting fees at risk, and in some cases, offering entirely value-based payment models (e.g. upside and downside risk) to clients,” the authors of the report wrote. “We continue to collect market intelligence on the broader adoption of these models alongside general employer appetite to incorporate quality metrics into vendor management contracting.”

References

1. Batiste B., Marcheva B. Market Perspectives. Morgan Health. January 2024.

2. Tracy D. Lilly Pens Open Letter Raising Concerns Regarding Use of Mounjaro for Cosmetic Weight Loss. Pharmaceutical Executive. News release. January 4, 2024. Accessed January 12, 2024. https://www.pharmexec.com/view/lilly-pens-open-letter-raising-concerns-regarding-use-of-mounjaro-for-cosmetic-weight-loss