The Business Case for Employer-Based GLP-1 Coverage

This past May, Pharmaceutical Executive reported that CVS Health decided to return Eli Lilly’s Zepbound to its list of covered medications, along with the addition of the company’s new oral GLP-1 Foundayo. CVS previously removed Zepbound from its formularies due to pricing negotiations with Lilly’s competitor Novo Nordisk.

This story is just the latest example in the ongoing issues GLP-1s face when it comes to coverage. While the drugs are known to be effective and safe, they are also in high demand and effective. As a result, coverage providers have struggled to include the medications, especially considering the wide swath of indications they can be prescribed for.

One area that’s been of particular interest is employer coverage. Companies want to be able to promote that their employees are covered for these in-demand drugs, but they also must consider other factors.

Pharmaceutical Executive spoke with Susan Thomas, chief commercial officer at LucyRx, about the company’s efforts to provide coverage models for GLP-1s and why its so important to provide these medications for general health purposes.

Pharmaceutical Executive: What is the business case for employer-based GLP-1 coverage?
Susan Thomas: What we're doing at LucyRx is giving plan sponsors more options and pathways that help them provide these medications to the highest-risk population. It's not a one-size-fits-all approach, and it's not a blanket inclusion or exclusion that, as I described, can send your pharmacy dollars running off the chart.

We've created a three-pathway option that starts with helping the plan understand its own population. What does their cohort look like, and who are the highest-risk members within it? Type 2 diabetics are easy to identify, and those patients are largely covered under most benefit plans today. The harder population to reach is the one without a diabetes diagnosis, members who are overweight or have obesity and carry cardiovascular risk, perhaps taking a statin or a blood pressure medication, but whose A1C hasn't yet crossed the threshold for a diabetes diagnosis. That's the population that often loses coverage when plan sponsors decide to exclude obesity as an indication. We can help define that cohort through claims analysis.

If a plan agrees with our approach (covering for diabetes, assessing cardiovascular risk and extending coverage to that population, and then separately addressing the broader overweight population that is indicated for a GLP-1 but has no other comorbidity) those members can be directed to our direct-to-employer net price program. That structure gives employers real visibility into their population and cohort, and then we help them build a benefit and copay structure, including member out-of-pocket strategy, that delivers coverage at a rate that's far more manageable than simply opening up access to all employees.

It's an innovative approach, but it really comes down to one thing: helping the plan understand its population, cover what it can sustainably over the long term, and build benefits that are both affordable and durable.