Pharmacy benefit plan costs are on the rise with increased utilization of medications for members seeking chronic weight management and treatment for type 2 diabetes.
There has been a surge in prescribing of a class of drugs known as glucagon-like peptide-1 (GLP-1) agonists that mimic a natural gut hormone causing blood glucose lowering and appetite suppression effects. Such endpoints are appealing to a growing population of people being diagnosed with diabetes and obesity, as well as those looking to use the medications off-label.
These medications are costing plans about $1,000/month per member and treatment is long-term; effects have been shown to reverse after discontinuation. To date the available branded products are either indicated for type 2 diabetes [examples include Mounjaro, Ozempic, Trulicity] or chronic weight management [Wegovy, Saxenda], but it is expected that dual indications are on the horizon. Mounjaro has been granted a fast track designation by the FDA to expedite the review for chronic weight management and is expected to be approved for that indication by year end.
The CDC estimates that over 70 percent of adult Americans are obese or overweight.
#OZEMPIC has taken social media by storm as users document their weight loss journeys across platforms further impacting prescription sales and it continues to do so as more and more people become aware of the desirable effects. The demand has led to medication shortages and increased investments into manufacturing facilities to expand production capacity to meet the growing request of these drugs such as Eli Lilly and its announcement to add $450 million in funds to a North Carolina plant.
These drugs are changing the landscape of weight loss management, they have the potential to help patients lose a clinically significant percentage of body weight and grow industry revenue. WeightWatchers plans to capitalize on the market with their recently announced acquisition of a telehealth platform [known as Sequence] to expand its existing programs with the addition of access to these blockbuster drugs. Launched in 2021, Sequence is a niche company that offers a subscription service to patients who want to lose weight with the assistance of GLP-1s such as Ozempic, Wegovy, and Mounjaro.
WeightWatchers’ CEO Sima Sistani stated that drugs like Ozempic are “the biggest innovation in our industry today.”
“Over a million prescriptions were written for Ozempic alone in December 2022, according to IQVIA, a rise of 64 percent over the previous December.”
PBIRx recommends requiring a prior authorization on all GLP-1 agonists to ensure that appropriate clinical criteria are being met for the corresponding indications and to prevent costs associated with inappropriate or off-label use. This guidance comes as an example of PBIRx’s extensive clinical research to better benefit our clients knowing that many PBMs will forgo management of these agents as they are in the business of increasing profits for their stakeholders.
While these medications are becoming more mainstream therapy for patients with diabetes and those seeking weight loss, it is imperative to stay abreast the climbing trend and implement a prior authorization requirement to proactively save plan sponsors thousands of dollars.