With the surge in popularity of the GLP-1 receptor agonists Saxenda (liraglutide injection, Novo Nordisk) and Wegovy (semaglutide injection, Novo Nordisk), and the recent FDA approval of Zepbound (tirzepatide, Eli Lilly), benefit managers are facing difficult decisions about coverage for these weight loss medications.

Although these drugs are effective in assisting patients with weight loss, they are also very expensive for employers and other payors to cover, with the average prescription for Wegovy or Saxenda reaching about $1,349 per month. Morgan Stanley analysts expect the anti-obesity market to reach $77 billion worldwide in 2030, which is an increase over the previous estimate of $23 billion.

Plan sponsors must consider many factors when deciding whether to cover GLP-1 receptor agonists for weight loss. The cost–benefit analysis may be different depending on each company’s individual priorities and financial capabilities.

What Are GLP-1s?

Glucagon-like peptide 1 (GLP-1) is a naturally occurring hormone that helps regulate blood sugar levels by stimulating insulin secretion and suppressing glucagon release. GLP-1s are often used with other medications and lifestyle changes to improve glycemic control and reduce the risk for complications associated with diabetes.

A typical side effect of GLP-1 use is appetite suppression, and in the clinical studies conducted for these drugs, meaningful weight loss was consistently a reported outcome (Clin Diabetes 2023;41[2]:226-238). This led to the FDA granting a new indication for some of the existing diabetic GLP-1 drug molecules, such as semaglutide and liraglutide, for weight loss, and subsequently being remarketed under a different brand name. Currently, Saxenda and Wegovy are the only two GLP-1s indicated for obesity and chronic weight management in the United States. Although the underlying drug molecule is the same whether treating type 2 diabetes or obesity, the dosing varies.

Considerations for Employers In Covering GLP-1s For Weight Loss

The weight loss medications have several benefits that could warrant coverage. Losing weight can lead to improved employee health, increased productivity and potential for future healthcare cost savings. Obesity can be tied to other chronic health conditions, such as diabetes, hypertension and hypercholesterolemia. By losing weight, employees may also decrease their risks for these conditions. Furthermore, when employees are healthy, they tend to feel more engaged and have more energy, improved focus and increased productivity levels. Emphasizing the importance of overall health and helping employees decrease their chances of developing weight-related comorbidities can potentially reduce healthcare costs through the reduction of drug costs, physician and hospital visits and insurance premiums.

Some individuals may perceive that an employer offering weight loss medications as a covered benefit places a higher value on the health and wellness of their employees than a company that does not allow coverage. For current employees, this coverage could lead to enhanced job satisfaction. Employees who feel prioritized with comprehensive healthcare benefits, including weight loss medications combined with other lifestyle modification programs, may experience morale boosts and a positive company culture. For prospective employees, the coverage of comprehensive weight loss benefits can be a nice perk, attracting a wider range of talented candidates. Prospective employees who prioritize their health and well-being are more likely to be attracted to companies that portray similar values through their benefit offerings.

3 Keys to Solving Coverage, Shortage and Budgetary Challenges

Every business will approach coverage questions about GLP-1 medications differently depending on how it aligns its mission and values to the insurance coverage it offers employees. It is important for these employers to work with a partner that can help navigate these complex coverage questions, costs and supply shortages with a solution that works for their organization.

Here are the most important aspects employers should keep in mind when choosing a pharmacy benefit manager (PBM) partner to help with these emerging trends:

Custom Criteria

Work with a partner who can provide custom prior authorization (PA) criteria as an option for your organization. This can help ensure the proper usage of GLP-1s across the board depending on how the employer wants the drugs to be covered. Moreover, understanding the manufacturer agreements for these drugs and what can, and cannot, be done with respect to clinical criteria is also important.

PBM-side Pharmacists

Collaborate with a PBM that has experienced pharmacists who know in advance when new drugs, such as GLP-1s, will launch and also can leverage relationships with drug manufacturers to maintain market prices and supply. This will help ensure the best price, availability of supply for providers and employees, and patients’ access to drugs during shortages.

Hands-on Partnership

Before considering changes to your PBM plans, work with a partner that will guide your team through decision making about coverage for such medications for weight loss, or if they should only be used as indicated. Depending on your decision, a partner can provide tools to ensure proper use by developing custom PA criteria in your PBM contract as well as provisions to support the best price and availability of supply.

—N.P. and K.K.

Although the benefits from choosing to cover GLP-1 agonists for weight loss are attractive in terms of employee and prospective employee satisfaction, there are several other important factors to consider in the decision-making process.

Despite the popularity of these medications, they do come with a high price tag. For companies with high utilization, these costs can add up quickly, and may ultimately become unsustainable for some employers. When implementing coverage for GLP-1 agonists for weight loss, ensure that the right procedures, such as prior authorizations, are in place to confirm that their use is in line with product labeling, and that users are meeting the expected clinical outcomes in terms of body fat reduction. Proper utilization management will also help to decrease the cost of the drugs by ensuring they are not being dispensed to those who do not meet the clinical requirements set forth by the manufacturers.

In addition to high costs, GLP-1 agonists can be associated with a high incidence of side effects and other risks. The side effects are primarily gastrointestinal, such as nausea, vomiting, diarrhea or constipation. These effects can be difficult to manage, and as a result, many users discontinue the medication (Diabetes Metab Syndr Obes 2017:10:403-412).

Although the efficacy of GLP-1 agonists has been tested, and there are compelling data to support their use in weight loss, results vary from patient to patient. Many people experience significant weight loss with these medications, but some patients may see minimal to no benefit. It is important to educate patients who are newly prescribed a GLP-1 for weight loss about the expected results, and that discontinuation is enforced if they are not achieving the expected clinical outcomes.

Furthermore, without the proper education, patients may depend only on the medication for weight loss, neglecting to change other lifestyle factors. If these medications are discontinued without implementing lifestyle modifications, rebound weight gain is extremely likely (Diabetes Obes Metab 2022;24[8]:1553-1564). To prevent this, patients may depend on the medication for an extended period, in turn driving up costs for the plan. It is also important to note that long-term outcomes with these medications are currently unknown, and it may be years before solid data are available to support extended benefit after discontinuation.

Nancy Price is the vice president of human resources strategic sourcing at HealthTrust Performance Group (www.healthtrustpg/ihp). She can be reached at Nancy.Price@healthtrustpg.com. Katie Komoroski is the director of pharmacy benefits strategy at HealthTrust Performance Group.

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