- Programs & Services
- Cost Management
- Specialty Management
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- Member Engagement
- Health Plan Client Engagement
Pulling the right levers to manage coverage and spend
Glucagon-like peptide 1 receptor agonists (GLP-1s) have emerged as groundbreaking treatments for metabolic health conditions. GLP-1s effectively lower A1C levels and have become first-line agents in treatment for type 2 diabetes.
To date, both Wegovy and Saxenda are approved to be prescribed for chronic weight management, along with a reduced calorie diet and increased physical activity, in individuals who either:
- Have a body mass index (BMI) of 30 or higher
- Are overweight and have one weight-related condition such as diabetes, high blood pressure, or high cholesterol
Other agents in the pipeline are expected to get similar approval soon.
Not surprisingly, these drugs have been in high demand. Supply shortages of these medications prompted off-label prescribing of Ozempic, Rybelsus, and Mounjaro for weight management, even though these agents are not indicated for weight management. Now that shortages are being remediated, prescriptions for approved weight management medications likely will continue to soar as medications become more widely available and new drugs come to market.
|500K+ new prescriptions for GLP-1s to treat diabetes and obesity in February 2023, an increase of 152% since last year
Due to the high cost of these drugs, as well as current research that suggests people who begin using GLP-1s may need to remain on them indefinitely to maintain weight loss and prevent weight regain, it’s important for plan sponsors offering coverage for approved weight management drugs to have utilization management (UM) strategies in place for balancing coverage and spend, as well as for helping to ensure clinically appropriate use.
Helping to ensure clinical integrity
Plan sponsors can employ a number of strategies to help ensure use of GLP-1s, whether for type 2 diabetes or weight management, is clinically appropriate and in accordance with FDA-approved indications. These may include:
- Formulary strategies, including new-to-market review, to help ensure clinically appropriate coverage from the start, as well as promoting lowest net cost agents in the category
- Prior authorization to evaluate whether a member meets appropriate FDA-approved labeling criteria, including confirmation of minimum BMI for weight management medications or confirmation of diagnosis of type 2 diabetes for diabetes medications, before beginning therapy
- Smart logic to bypass prior authorization for members who have been prescribed GLP-1s approved to treat type 2 diabetes, if their records indicate they meet clinical criteria, enabling them to begin appropriate therapy faster with minimal disruption
- Step therapy, when appropriate, to encourage members and their providers to try alternative options first that may be less costly and may not require indefinite duration for treatment
- Condition management to integrate lifestyle changes and nutrition support into a more holistic approach to treating type 2 diabetes and obesity, as clinical studies have shown increased effectiveness in weight management when GLP-1s are paired with lifestyle interventions
Day-one management of new-to-market weight management medications
As this class of medications rapidly expands, plan sponsors who want to manage coverage of new weight management medications as they come to market could implement a solution such as our Weight Management UM Bundle. The bundle includes UM criteria for select weight management agents,
Minimizing disruptions for members with diabetes
While prior authorizations are key to reduce GLP-1 prescribing amongst patients who do not have type 2 diabetes, it can be disruptive for members who do. Smart logic can be put in place to bypass the prior authorization requirement for individuals whose records include a diabetes diagnosis or previous fill for type 2 diabetes medications over the last two years. This enables a smoother experience for members who are on ongoing diabetes treatment regimens while reducing the number of prior authorizations overall.
|Nearly 800 CVS Caremark clients adopted a GLP-1 smart logic edit in the first two months the offering was available|
As the treatment landscape for metabolic health care continues to evolve, CVS Caremark is supporting employer and health plan clients by putting in place solutions that allow for a balanced approach to managing coverage and spend.
The source for data in this document is CVS Health Enterprise Analytics, unless otherwise noted. CVS Health uses and shares data as allowed by applicable law, and by our agreements and our information firewall.
This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Health.
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