Employers take ‘wait-and-see’ approach on expanding GLP-1 drug coverage

Glucagon-like peptide-1, or GLP-1, medications garnered widespread public attention within the past year, but many employer-sponsored health plans have so far held off from covering them, speakers at a Marsh McLennan Agency webinar said Tuesday.

Last year, the Food and Drug Administration approved Zepbound as a medication for weight loss. Another drug, Wegovy, previously had been approved for this purpose in 2021 and last month gained approval for use to reduce the risk of heart attack, stroke or death in people with cardiovascular disease.

GLP-1 drugs have shown several benefits, according to Heidi Orstad, regional clinical consultant with MMA’s planning and analytics for total health division. When taken as written, patients have been able to lose weight and realize cardiometabolic health advantages.

But research has shown that these benefits may subside when patients stop taking the drugs, even when patients receive lifestyle and wellness education, she said. 

That is something to note given at least one 2023 analysis found that most patients taking drugs like Wegovy had stopped taking the drug within a year, Reuters reported. Orstad said some of this trend is due to the high cost share patients must pay for GLP-1 drugs, but side effects such as gastrointestinal discomfort also contribute.

“It’s important to follow the science and what’s been published about these medications,” Orstad added.

Most MMA clients are taking a “wait and see” approach and opting to see how the market for GLP-1 drugs changes over time, said Malissa Moss, also a regional clinical consultant for MMA’s planning and analytics for total health division. Employers may be uncertain as to how many plan enrollees are interested in the drugs for weight-loss purposes, she said.

Those factors are all top-of-mind for employers given rising prescription drug costs. MMA has estimated that if current prescription costs trends continue, employers could see their expenses in this area grow to be larger than the inpatient, outpatient and physician and professional services categories of healthcare combined, said Rick Kelly, pharmacy practice leader at the firm.

Kelly said employer-sponsored plans could minimize their exposure to GLP-1 weight loss prescription costs by setting eligibility criteria such as requiring participation in holistic weight loss programs, higher body mass index requirements for those taking GLP-1 drugs and higher cost-sharing for plan participants

But those not covering GLP-1 drugs for weight loss risk exposure to situations in which plan participants seek to use the drugs off-label, he added. The medications can be used to treat Type 2 diabetes, and pharmacy benefit managers may have relatively lax prior authorization standards for GLP-1 drugs in the Type 2 diabetic context, Kelly said.

“It’s really important that there’s an independent assessment of, what is the proper authorization assessment for the PBM to make sure they’re really only allowing the Type 2 diabetics to get that medication,” he added.

Plan participants may still seek alternative access to GLP-1 treatments outside of the employer-sponsored plan context. For example, Moss said she has seen an uptick in venues such as spas and health clinics that advertise semaglutide treatments. That is concerning, Moss added, because patients who choose this route may not be monitored by their primary care providers, who know about medical conditions that could lead to adverse side effects.