Obesity is a complex, chronic condition. And it’s more common than ever before in the United States, due to factors like metabolic changes, eating patterns, nutrition in the standard American diet, and physical activity levels.
Along with the rise in levels of obesity, weight management drugs have become a hot topic. GLP-1s are a groundbreaking class of medications that help drive weight loss by changing brain signaling. And research shows that they’re extremely effective.
But these drugs are also expensive, and demand for them is high. Plan sponsors need to approach this topic carefully, especially as more novel treatments come to market. Let’s start with the basics.
What are GLP-1s, and why do they matter?
GLP-1s are a novel class of medications that drive weight loss by impacting brain signaling around appetite, hunger, and satiety. Because these drugs can be so effective, physicians are changing the way obesity (and its frequently co-occurring condition, diabetes) is treated.
Both conditions are highly prevalent. Obesity affects 70m US adults, and more than 37m adults have diabetes. The use of GLP-1s in treatment has skyrocketed over the past few years, and the upward curve shows no sign of slowing: The category could reach more than $77b in global sales by 2030.
What challenges come with GLP-1s?
This innovative treatment option has been great news for people who struggle with obesity and its related conditions. So what’s the catch? For starters, these drugs are pretty pricey, resulting in significant cost increases for payors.
If every US adult with obesity were prescribed a GLP-1 agonist, the cost would total $1.2t. And while only 230,000 scripts were written for GLP-1s in 2019, that number exceeded 9 million in 2022 and continues to grow. The category could reach more than $77 billion in global sales by 2030.
And price isn’t the only challenge to consider. With varying degrees of efficacy, adverse side effects, and adherence challenges—as well as potential downstream health outcomes—plan sponsors have a lot to consider as they decide whether to prescribe these meds.
How should plan sponsors stay ahead and approach GLP-1s?
CVS Caremark recommends an evidence-based approach to efficiently manage the dynamic GLP-1 category. That starts with sponsors taking the time to consult with their PBM and evaluate the unique health needs of their covered populations, crafting an approach to GLP-1s that combines coverage, cost, and care.
Coverage decisions will depend on each plan sponsor’s benefit philosophy: Whereas some would prefer to focus coverage on addressing existing health conditions, others may prefer to provide coverage for weight loss medications that may reduce downstream pharmacy and medical spend. Working with their PBM, they will likely find that there are a number of utilization management options, ranging from less to more restrictive. These may include quantity limits, step therapy, and prior authorization.
And if we really want to address the cost issue? Well, a comprehensive care management program can also increase savings on GLP-1s and promote better health outcomes for members. This class of drugs, like others, is most effective when dosed appropriately and paired with lifestyle changes including diet and exercise—care management programs serve to support this view.
GLP-1s for weight loss come with persistence and adherence challenges. One study showed that a whopping 68% of commercial plan members had stopped taking their medications by the end of the first year. Providing a robust care management program that includes nutrition and lifestyle coaching can help control costs and ensure that weight loss is sustainable. Win-win.
Ultimately, plan sponsors should work directly with their PBM on thoughtful, data-driven coverage decisions. With the PBM’s comprehensive options and available modeling, sponsors can make informed decisions throughout the treatment process, from medical cost avoidance to pharmacy spend savings.
CVS Caremark works directly with benefits managers to build connected pharmacy plans that support their organizations’ priorities and budget and give providers real-time data to make informed decisions—so members can get the care they need when they need it. Learn more about Caremark’s integrated PBM model.