Introduction to GLP-1 Drug Costs
As insurers struggle with GLP-1 drug costs, some seek to wean patients off. After losing 50 pounds on the injectable weight loss medication Zepbound, Kyra Wensley received a surprising letter from her pharmacy benefit manager in April. Her request for coverage had been denied, the letter said, because she’d had a body mass index of less than 35 when she started Zepbound. The 25-year-old who lives in New York had been taking Zepbound without incident for months, so she was confused: Why was her BMI, which had been around 32 when she started, becoming an issue only now?
The Struggle with GLP-1 Coverage
Wensley had no interest in quitting an effective drug. “Going right off like that, it’s easier said than done,” she said. Her doctor fought to keep her on the GLP-1 agonist, the category that includes weight loss and Type 2 diabetes drugs Ozempic, Wegovy, Mounjaro, and Zepbound. But Wensley ultimately had to switch from Zepbound to Wegovy to meet her plan’s requirements. She said she doesn’t like Wegovy as much as her old medication, but she now feels lucky to be on any GLP-1.
Kyra Wensley’s doctor fought to keep her on the injectable weight loss medication Zepbound, but Wensley ultimately had to switch to Wegovy, a different GLP-1 agonist, to meet her health plan’s requirements. ((Lori Wensley)/KFF HEALTH/TNS)
The Pressure on Public and Private Payers
Lots of research suggests such medications must be used indefinitely to maintain weight loss and related health benefits. But with list prices of roughly $1,000 a month, public and private payers are struggling to keep up with ballooning demand for GLP-1 weight loss drugs and in some cases are eliminating or restricting their coverage as a result. North Carolina Medicaid plans to end GLP-1 coverage for weight loss on Oct. 1, just over a year after starting the coverage. Pennsylvania is planning to limit Medicaid coverage to beneficiaries at the highest risk of complications from obesity.
The Concept of Deprescription
Already, many GLP-1 users quit within a year, studies suggest — often due to side effects, high costs, or insurance issues. Now a growing number of researchers, payers, and providers are exploring deliberate “deprescription,” which aims to taper some patients off their medication after they have taken it for a certain amount of time or lost a certain amount of weight. The U.K.’s National Institute for Health and Care Excellence, which creates guidance for the National Health Service, recommends two-year limits on the use of some weight loss medications, such as Wegovy.
Exploring Alternatives
A. Mark Fendrick, who directs the Center for Value-Based Insurance Design at the University of Michigan, has argued that if some people using GLP-1s to lose weight were eventually transitioned off, more people could take advantage of them. “If you’re going to spend $1 billion or $100 billion, you could either spend it on fewer people for a long period of time, or you can spend it on a lot more people for a shorter period of time,” he said. Fendrick’s employer, the University of Michigan, indeed does that. Its prescription drug plan caps coverage of GLP-1 drugs at two years if they’re used solely for weight loss.
The Challenge of Maintaining Weight Loss
Studies have shown that people typically regain a substantial amount of weight within a year of stopping GLP-1 medications, and that many people who quit ultimately go back on the drugs. “There’s no standard of care or gold standard on how to wean right now,” said Allison Adams, an obesity and internal medicine doctor with UK HealthCare in Kentucky. But the math shows why time-limited coverage is appealing to payers that struggle to pay for beneficiaries’ GLP-1 prescriptions, said Michelle Gourdine, chief medical officer for the pharmacy benefit manager CVS Caremark.
Conclusion
As the demand for GLP-1 weight loss drugs continues to rise, public and private payers are under increasing pressure to find ways to manage the costs. While some researchers and payers are exploring the concept of deprescription, others argue that maintaining access to these medications is crucial for patients who have found them effective. Ultimately, the key to responsible coverage may lie in providing a range of support options for patients, including behavioral health programs and more affordable alternatives.
FAQs
Q: What are GLP-1 drugs, and how do they work?
A: GLP-1 drugs, such as Ozempic, Wegovy, Mounjaro, and Zepbound, are a class of medications that mimic the action of a natural hormone in the body to help with weight loss and blood sugar control.
Q: Why are public and private payers struggling to cover GLP-1 drugs?
A: The high list price of GLP-1 drugs, roughly $1,000 per month, is putting a strain on public and private payers, leading some to restrict or eliminate coverage.
Q: What is deprescription, and how does it relate to GLP-1 drugs?
A: Deprescription refers to the practice of deliberately tapering patients off their medication after a certain period of time or weight loss. Some researchers and payers are exploring this concept as a way to manage the costs of GLP-1 drugs.
Q: What are the potential risks of stopping GLP-1 medications?
A: Studies have shown that people who stop taking GLP-1 medications often regain a substantial amount of weight within a year, and may be at risk for related health problems.
