Closing the GLP-1 Coverage Gap: Q&A with Susan Thomas

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.

Click here for the full interview!

Pharmaceutical Executive: What gaps continue to exist in GLP-1 coverage in the employer benefits market?
Susan Thomas: Most employers think of GLP-1 coverage in two buckets: one for type 2 diabetes and the other for weight loss. The gap is that pharmaceutical manufacturers are studying these drugs for many more indications, including cardiovascular disease, liver disease, kidney disease, and other conditions well beyond weight loss. When we limit coverage to just those two buckets, there's a whole population under employer coverage that may not get access when it's actually needed.

It's still early in terms of what we're going to see from an outcomes standpoint for these medications, but the cost has made coverage unaffordable and unsustainable, both for members and for plan sponsors. These drugs aren't as expensive as some of the biologics you might see in specialty pharmacy, which can run $80,000 to $100,000 a year. GLP-1s are more like $1,100 a month, so if a patient stays on the medication, you're looking at roughly $12,000 to $15,000 a year.

But when you open up coverage for obesity, for example, Wegovy can easily become your number one medication by cost, simply because of the volume of people the medication is indicated for. Obesity is an epidemic in this country. Over 50% of the population is overweight and could potentially be indicated for these weight loss agents. When you open up the floodgates, you face the challenge of spending an enormous share of your pharmacy dollar on these medications. That's simply not sustainable the way things exist today.

PE: What impact has research into the cardiometabolic benefit of GLP-1s had on coverage?
Thomas: Investment in GLP-1s is certainly a cost consideration. The longer-term benefit of improving cardiovascular risk is a longer journey. As a plan sponsor, you may not see immediate savings on medical costs, reductions in heart attacks, strokes, and those kinds of events right away. But when you commit to the long-term benefit, that's when you'll see those cost savings materialize.

Plan sponsors often focus on the immediate cost implication rather than the long-term return, and that's why GLP-1 coverage has become a budget line item rather than a strategy for serving a population over the long haul.

PE: What is the business case for employer-based GLP-1 coverage?
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.

PE: Why is GLP-1 coverage important for menopause?
Thomas: Women in that age range are disproportionately impacted by cardiovascular risk because of the metabolic changes that occur during perimenopause and menopause. The reduction in estrogen creates a cascade that directly affects cardiovascular risk in that population, with or without obesity. Over the course of a decade or two, from roughly age 45 to 65, women tend to gradually increase their weight, accumulating belly fat and visceral fat, which we know carries a direct correlation to cardiovascular risk.

If a plan sponsor has chosen not to cover GLP-1s for weight loss, women in that high-risk category are left without access to these medications unless they pay out of pocket, which runs roughly $350 to $450 a month and is largely unaffordable for most people. So women who gradually accumulate weight and cardiovascular risk over a decade or more are simply left without options.

That's a population we're particularly focused on at LucyRx. We want to help plan sponsors understand that cohort and build benefits around it, not just to reduce the likelihood of a stroke or heart attack, but to advance benefits equity within their plans. Women in this stage of life are often at the peak of their careers, and helping them navigate the symptoms of menopause, manage the associated cardiovascular risk, and sustain their career vitality is something we take very seriously.