How To Reduce Or Eliminate Your Benefit Spend For The Latest Diet Drugs Like Wegovy And Mounjaro

Robert Schenk,RPh
Oct 14, 2023
4 min read

October 14, 2023

In 2023 many employers have experienced unexpected and unbudgeted prescription benefit cost increases as much as 3 to 4 times their previous spend for certain drugs used to treat diabetes or weight loss. These drugs are known as the GLP-1's and include the diabetes drugs Ozempic and Mounjaro as well as FDA-approved weight loss agents Saxenda and Mounjaro. (Mounjaro is expected to be approved for weight loss by the FDA by the end of 2023). Unlike many diet trends of years gone by, these drugs actually work to reduce weight with relatively few known side effects compared to older drugs and the GLP-1's are here to stay. Unfortunately, annual costs for these drugs can run upwards of $10,000 to $15,000 per patient per year . If you have 1,000 beneficiaries who are using these drugs your drug spend may have just increased by $ 15 Million annually....or did it? (Stay tuned to the end of this post to see what real net costs may be!) Unlike the exploding drug benefit costs from new Hepatitis-C drugs a few years back which treated and CURED the disease with one course of therapy, weight loss patients must keep using these drugs chronically to maintain weight loss.

GLP-1's Price 2023 Benefit Plan Costs — GLP-1's Impact On 2023 Prescription Benefit Plans

Eliminate Coverage For Weight Loss Or Manage Access And Costs?

The exploding costs for these drugs has caused employers to scramble to find ways to manage costs or eliminate coverage altogether. One dilemma for employers is that the GLP-1's are effective at both decreasing blood sugars for diabetes patients and helping reduce weight in an ever increasing number of overweight and clinically obese workers. Helping workers stay healthy is a long term goal for most employers so looking for solutions to manage costs while helping workers stay healthy is a goal of most HR Benefits Decision makers. Not covering weight loss drugs is an option chosen by over 40% of employers and may not be in the best interest of maintaining a healthy workforce in the long term, but may be a business decision out of necessity to reduce benefit costs to stay in business. For employers who do want to continue coverage (and can absorb the benefit cost increases), managing access for appropriate patients can be a great strategy. For employers wavering on this decision because of the recent benefit cost explosion some additional factors below for your consideration are described by the Pharmacy Benefit Forensics Team

Access Management Strategies

There are several ways to manage access once a decision for continued coverage has been made.

Manage the access by tightening the Prior Authorization Criteria: Standard PBM Weight Loss Drug PA criteria allows most people easy access. The BMI required for access can be INCREASED to only severely obese patients
Manage access by routing all GLP-1 claims through a gatekeeper prescriber: Prescribers including GPs and Family Docs are getting pressured from their patients to prescribe these meds and usually try to accommodate them. What doctor wants to deny their patient with motivation to lose weight or tell them to try diet and exercise when there may be an easier way? Patients can be directed to a "Weight Loss Center of Excellence" to ensure they are appropriate candidates, are informed and have tried lower level (and lower cost) therapies first. Medical spend may increase but if done properly the drug cost decrease will be multiples of the physician costs.
Manage access by routing through a special pharmacy provider network- Some pharmacies , including internet pharmacies, have suddenly become "experts" in shepherding patients and claims through the system. Restricting access to only known pharmacies or your PBM Mail or Specialty pharmacy may help eliminate some potential FWA

Cost Management Strategies -The Impact Of Manufacturer Rebates, Variable Copay and Limiting Days Supply

Reduce waste by limiting days supply; Most of the GLP-1s require gradually increasing doses due to side effects that many patients cannot tolerate. Work with your PBM to limit all prescriptions to 30 days supplies. This also helps mitigate supply issues the manufacturers are experiencing because they cannot produce enough to meet nationwide demands!
New plan design options allow the manufacturer to help offset higher level copays; Manufacturer copay discount coupons are readily available for your employees however many employers have standard copays that limit the benefits available from these cards. If a GLP-1 manufacturer is ready, willing, and able to cover a $200 copay, let them! Work with your PBM to determine if you can modify your plan design and allow a Variable Copay depending on manufacturer copay assistance. Tapping into this one option can save up to 20% of the plan drug cost
Consider the NET COST to the plan after quarterly PBM rebates. Although everyone is shocked by the top dollar plan cost increases and is feeling the pain of paying those monthly PBM invoices don't forget that as high cost brand name drugs you are hopefully getting pass through of INCREASED rebates from your PBMs in the form of larger rebate checks. Rebates alone are likely returning 30 to 40% of your new spend on these drugs.

Between Rebates and a Variable Copay design you may reduce your GLP-1 spend by approximately 60% of the top line cost. Implementing access controls like enhanced Prior Authorization, Quantity Limits and ensuring a qualified gatekeeper and pharmacy will help reduce your spend even further for these agents. There are multiple strategies to help manage your spend and allow qualified and appropriate patients access to these new drugs. They will be with us for quite some time, at least until they are replace by oral versions that work as well!

Pharmacy Benefit Forensics Pharmacists are constantly working to develop strategies that employers can use to eliminate fraud, waste and abuse as well as to better manage limited drug benefit resource dollars. Whether to eliminate coverage for these drugs or deploy strategies that reduce your financial risk can be a tough decision but hopefully some of these strategies can help your decision process. Please contact Pharmacy Benefit Forensics for more information.

Robert J Schenk Jr., RPh, CCP

President & Chief Investigative Officer

Do you currently cover GLP-1's for weight loss?