GLP-1 Management: Flexible Strategies for Plan Protection and Sustainable Savings
GLP-1s, originally developed for diabetes management, have surged in popularity due to their effectiveness in weight loss. This dual-purpose use has led to skyrocketing demand, putting significant financial pressure on payers. Compounding this challenge is a pipeline filled with more GLP-1 and related therapies expected to enter the market, further driving up potential costs.
Given the rapid adoption and expense of these drugs, plans must take a strategic approach to coverage decisions. Unlike some drug categories where clinical use is more clear-cut, the use of GLP-1s for weight loss adds a layer of complexity. GLP-1 coverage decisions can impact the financial health of the plan, both in the short and long term, and payers should have the flexibility to determine their own coverage policies. Without a thoughtful clinical coverage strategy and the flexibility to make decisions for their member population, plans risk unchecked spending in this rapidly growing category.
Payers Need the Flexibility to Manage Their Plan Their Way
Flexibility and plan control are key to successful management of GLP-1 spend. When selecting a pharmacy partner, plans should question how decisions are made about GLP-1 coverage. Is coverage for weight loss mandatory? If not, can those medications be covered for new and expanded indications? These decisions are unique to each plan, not a one-size-fits-all. Pharmacy partners should provide expert guidance, but the final decision should be with the plan itself when it comes to choosing what to cover.
Careful Management For Each Indication Provides Appropriate Access
Unlike some drug categories where clinical use is more clear-cut, the use of GLP-1s for weight loss adds a layer of complexity. Having clinical criteria and guidelines unique to each indication, both diabetes and weight loss, helps provide appropriate access for members. Read below for best practices for GLP-1 management.
Chart Notes: Requiring prescribers to provide more information than just “checking the box” when indicating a diagnosis of Type 2 diabetes ensures GLP-1s are being used as intended. This prevents off-label use and is especially important for plans that exclude GLP-1s for weight management.
Supply Limits: Because patients using GLP-1s are at high risk for discontinuation, limiting the supply to 30-days can prevent waste on this costly medication if a dose is titrated upwards or down, or if the product is discontinued for any reason.
Plan Control: GLP-1s can be costly, so plans should have the ability to decide how they will cover them. Covering or excluding GLP-1s for chronic weight management should be based on the unique needs of the plan and their member population.
Expanded Indications: Plans that exclude GLP-1s for chronic weight management should be able to choose to cover for expanded indications only. Your partner should not mandate their use. Examples include, Wegovy for major adverse cardiovascular event (MACE) risk reduction or Zepbound for Obstructive Sleep Apnea.
Appropriate Access: If your plan decides to cover GLP-1s for weight management, a requirement of chart notes ensures access to only the most appropriate population (body mass index requirements with comorbidity) and that lifestyle modification is addressed. Authorization timeframes should also be shortened to ensure patient response to therapy and weight loss has been achieved.
In a rapidly evolving therapeutic landscape, managing GLP-1 utilization requires a balance between clinical appropriateness and financial sustainability. Plans need the freedom to develop tailored strategies that reflect the specific needs of their populations, without being bound by one-size-fits-all mandates. With the right pharmacy partner that respects plan autonomy and provides clinical expertise, payers can make informed decisions that support appropriate access while keeping financial sustainability in mind. By implementing flexible, indication-specific policies and requiring clinical documentation, plans can protect against overspending while still providing members access to the medications they need.
