The Remaining Gaps in Employer-Covered GLP-1 Benefits

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 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.