Weight management in the era of GLP-1s 

As the market for weight-loss GLP-1s has moved toward maturity, and manufacturing and supply issues have begun to resolve, employers, PBMs and point solution vendors have explored – and are implementing – new strategies to manage the growth in spending on this class of drugs.

Some of these strategies address managing utilization, both for drugs specifically approved for weight loss, as well as the off-label use of those approved for treatment of diabetes. Other strategies look at weight management more holistically, maintaining that while GLP-1 therapies should not be the first approach tried, if they are needed, they will be most successful in conjunction with support for lifestyle changes.

In this post, we will review both types of strategies, and discuss how data analysis can help guide employers in making decisions that best fit their plan population and their benefits philosophy.

Utilization controls through prior authorization, step therapy and plan design

In addition to standard prior authorization, step therapy and quantity limits, some carriers offer more aggressive management criteria, such as higher BMI thresholds, that prioritize the most at-risk members for treatment with GLP-1s. While more aggressive criteria have historically been tied to a loss of rebates, some of the newest offerings preserve at least a portion of the rebate for employers.

Other innovative offerings include weight-management GLP-1 trend and ROI guarantees. Employers may also define requirements for participation and engagement in lifestyle management programs. Before implementing any custom criteria, it is important to understand the impact on manufacturer rebates.

Some employers have explored plan design changes to increase member cost share or leverage the availability of manufacturer coupons. Others have revisited the inclusion of GLP-1s on the preventive drug lists that allow members to bypass deductibles.

Still others have explored applying annual or lifetime benefit limits for GLP-1 drugs as a mechanism to control costs. Not every approach is a good fit for every employer, and all options should be vetted with the employer's overall benefit philosophy in mind.

Innovations in weight loss GLP-1 management

When treating obesity, GLP-1 medications are one of many tools in providers’ toolkits. Support for patients living with obesity should consider the whole person and address issues such as sleep, stress, poor nutrition, inactivity and mental health concerns.

Comprehensive weight management approaches promote not only weight loss but also “non-scale” victories that contribute to overall health and wellbeing. It is important to think beyond prescribing to support patients who are utilizing GLP-1 medications, which are meant to be prescribed in tandem with coaching or guidance for lifestyle modifications.

Employers should ensure these members have access to a program that offers prescriptive nutrition recommendations and addresses behavior and choices and can support a medical taper strategy. When members are supported holistically, clinicians can identify and address side-effect concerns and potential risk for vitamin/mineral deficiencies, while setting the patient up for long-term success with or without the medication.

New offerings from PBMs incorporate a digital or telemedicine-based lifestyle management component into the utilization management process for weight-loss drugs. These programs generally rely on PBM-curated point solutions to administer lifestyle management programs. Employers should review these new offerings in the context of their existing carrier and point solution ecosystem from a fit, focus and member experience perspective.

Vendors are developing solutions in the GLP-1 space that involve weight management, prescribing, diabetes/hypertension management, pre-diabetes and more. Any of these solutions may have a role to play in your program’s overall cardiometabolic strategy, but in reviewing the vendor landscape it will be important to first clarify your own philosophy toward weight management so you can better evaluate each vendor’s approach. Do they offer one diet for all? GLP-1 medications for all who qualify? Personalized support with a registered dietitian?

Beyond the standard objectives of engagement, satisfaction, member experience and clinical outcomes, employers should also evaluate and review other key areas: Is the approach evidence based? Is the vendor leveraging the appropriate clinicians? How does this solution support the clinical management of the high-risk population? How are recommendations personalized? How is the solution leveraging AI? What is the level of behavioral health support? How is the solution addressing health equity concerns?

Other emerging management strategies, in addition to partnering with a vendor, you may want to consider:

• Requiring active participation in programs to support behavior change prior to or in conjunction with weight-loss drug approval. Employers will need to think through the definition of “active participation,” how it will be monitored and enforced and what entity will be responsible for monitoring.
• Carving out prior authorization, drug fulfillment and prescribing of GLP-1 and/or other weight-loss medication to a vendor (similar to carve-out solutions for fertility services). Employers will need to carefully evaluate the financial and operational impact of any carve-out solution to their existing PBM or carrier contract.
• Excluding weight-loss drug coverage but offering an HRA contribution incentive for members who engage in lifestyle programs. Members can access the drug directly via telemedicine (e.g., through the Lilly Direct service), often at a lower cash price than what is available to employer plans. Members can then request reimbursement from the HRA.

Understanding your population to determine effective GLP-1 cost management strategies

Wherever you are on the spectrum of opinion on GLP-1 drugs for weight loss – covering them now, considering or not considering – data analytics can help you design or refine strategies for effective cost management. Many employers are concerned that GLP-1s are being leveraged as first-line therapy for members newly diagnosed with diabetes and may want to ensure that metformin is being used first line when clinically appropriate. If data analysis reveals that many diabetic members without cardiovascular or kidney disease have not tried metformin before starting a GLP-1, adding a step-therapy requirement to drive members to this lower-cost option could reduce costs for the member and plan sponsor.

Claims data can also be leveraged to understand the extent of off-label use of GLP-1s indicated for type 2 diabetes (e.g., Ozempic, Mounjaro) to assist in weight loss. Assessing the medical data to confirm utilizers have a type 2 diabetes diagnosis enables employers to determine whether a prior authorization is needed. Conversely, when a prior authorization process is in place, the lack of a type 2 diagnosis can highlight that the protocol is not working.

Employers also continue to receive pressure to cover GLP-1s for weight loss. When considering coverage, employers want to know what percentage of the plan’s population without diabetes might hit the weight threshold for being considered obese (typically a BMI of 30 or more). They also want to explore how their exposure would change if the prior authorization criteria were modified to increase a BMI to 32 or 35. Data can assist the employer in answering these questions as they develop a utilization management strategy. As previously stated, changes to the criteria can impact rebates.

Staying on top of fast-moving developments

As new indications for GLP-1 medications are studied and approved, and employers, PBMs and vendors continue to innovate cost management strategies, it will be important to revisit your organization’s approach towards covering and managing this important class of drugs.

Plan design changes may have unintended consequences, or no real effect. Social media exposure may result in still more pressure to provide coverage. New products may become available and pricing for existing products may change. Today’s management solutions may be eclipsed by more effective ones.

Leveraging data regularly to understand key utilization and behavioral trends will provide valuable guidance needed to respond to marketplace changes and calibrate your approach to your unique workforce and business needs.