Top GLP-1 Questions from Health Plan and Employer Leaders, Answered

Virta Health and Brown & Brown hosted a live discussion on The Future of GLP-1 Pricing, Legislative Policy and Drug-Free Alternatives featuring expert insights from Western Health Advantage, Navitus, PillarRx, and Virta. The goal: to help health plan and benefits leaders prepare for what’s next when it comes to managing consumer demand and rising healthcare costs related to GLP-1s. 

With more than 600 healthcare leaders on the line, our panelists weren’t able to answer all of the questions live. To finish the discussion, the experts answered the outstanding questions here. You can also revisit the discussion on-demand.

GLP-1 Cost Implications and Strategies to Manage Them 

Health plan leaders have said GLP-1s would bankrupt their pharmacy budget. What industry trends should they be following to ensure this doesn’t happen?

In the simplest of terms, a health insurer’s job is to use the premium they get to cover the cost of healthcare. If they spend all of that premium on one medication, the plan will not be able to cover other costs. To plan ahead, leaders should follow the regulatory environment and look at medical evidence for being on GLP-1s. They also need to understand the cost implications of both side effects as well as the way GLP-1s might be beneficial for other conditions, like cardiovascular disease, and how those things factor into the total cost of care. 

Is the investment in costly GLP-1s worth it for employers when the value may not be achieved until far in the future when employees may have already departed the organization?

Living with obesity increases total medical cost by $2-3k per person per year¹, and obesity is a risk factor for other serious conditions, like cardiovascular disease and diabetes. Whether your organization covers GLP-1s or not—a comprehensive metabolic health strategy is critical to balancing cost, access and outcomes. Covering GLP-1s can be worthwhile with the right strategy in place. GLP-1 use is indicated to be alongside lifestyle modifications. If GLP-1s are continued, weight loss is likely to continue or at least plateau. If the GLP-1 is discontinued without an appropriate lifestyle program, weight regain is likely and it will be a wasted experiment. The reality of this concern was highlighted in the The Guardian, which reported on a new study showing people who stop weight loss drugs return to their original weight within a year. Organizations that cover GLP-1s for weight loss should ensure they are optimizing those investments, for example holding their partners accountable for outcomes, to ensure pharmacy budgets aren’t wasted. 

How should I be navigating rebates? I can’t afford to lose my rebate. 

This is a daunting risk for employers, and it can be hard for benefits leaders to answer without full price transparency. Ultimately, it comes down to math. If the impact on trend is more than the rebate, putting stronger controls into place could be an option. In a recent employer forum, one employer shared they put in more stringent BMI requirements, which cost them their 30% rebate. However, they ended up seeing a 50% improvement in trended cost, so they still ended up 20% better off than if they hadn’t taken action for fear of impacting rebates. We do think we’ll start to see more people doing this type of analysis as the cost of GLP-1s continues to skyrocket. 

GLP-1 Access

How does provider oversight help patients get the most from GLP-1s when taken?

Taking a GLP-1 is a complicated experience for patients. It is critical that those who could benefit from taking the medication—regardless of where they are filled—do so under the guidance of an experienced provider who can see them as often as needed to support adherence, titration, side-effect monitoring, and ensure lifestyle changes are happening at the same time.

Virta is a virtual provider with licensed, board certified clinicians in all 50 states, and its protocols have been developed with input from endocrinologists and obesity medicine certified physicians. Its providers have over 100,000+ member years of experience managing cardiometabolic medications like GLP-1s, offering provider-led support tailored to each individual with the goal of deprescribing medication.

How will things change as these drugs become generic and offered in different forms in the years to come? 

Generics, oral forms, and new market entrants could change things, but as discussed live, panelists agreed it is unlikely we would see immediate relief or that these new medications would address the current spend problem overnight. Health plans and employers need more than a “hope that things will work out” strategy. 

Utilization Management

What kinds of plan design changes are being implemented specific to GLP-1s?

Plans are trying to find balance and determine what appropriate coverage looks like. Today, we’re seeing them employ a mix of utilization management strategies including step therapy, prior authorization and lifestyle programs to manage the GLP-1 cost tsunami. A recent Virta survey of health plan leaders across the US found growing momentum for lifestyle programs. 65% of executives now believe that lifestyle programs should be used as a first-line therapy in treating obesity, prior to prescribing a GLP-1. Virta responded by launching responsible GLP-1 prescribing capabilities as an expansion of its Sustainable Weight Loss offering. Early, compelling results show responsible prescribing cut GLP-1 use for weight loss over 50% while driving significant and sustained outcomes.

How easy is it for prescribers to successfully circumnavigate prior authorizations for GLP-1s? Are members able to gain access to them despite the plan not covering anti-obesity medication?

We are seeing evidence of increased off-label usage of GLP-1s (estimates of 20-40%), and a number of new indications such as those for cardiovascular disease with a BMI > 27 (overweight or obesity) and obstructive sleep apnea with a BMI > 30 (obesity), a list we expect will continue to grow. Where there is motivation, people will find a way to obtain the medication. Prescribers are attesting to non-obesity indications, sometimes validated within the medical record and sometimes not, and pill mills and wellness spas are promoting access to the drugs as well. This makes it more important than ever that access to GLP-1s is provided through safe, trustworthy channels. 

How do we know if our current PBM model is the best choice? 

Choosing your PBM is a crucial part of any cost-containment strategy. Your PBM should be willing to commit to and report on financial performance and adjust accordingly throughout the contract term, not just in annual retrospect. It is also useful to use a consultant you trust who is transparent. Their selection of and ongoing monitoring of your PBM’s performance should be objective, free from any revenue opaqueness. Data driven recommendations that consider the unique goals of the payer and/or employer are core competencies you want to look for.  

Side Effects

What concerns do you have about real-world effectiveness, adherence, and side effects? 

With limited data available yet on long-term side effects, it’s hard to say. There are data available that show these medications are not proving as effective in the real world as they did in clinical drug trials, with one study finding that patients did not achieve nearly as much weight loss, 7% on average, compared to 15% observed in drug trials².

There are also significant questions on persistence in the real world - will patients be able to stay with these drugs over time. Some early indicators suggest that the majority of people who start a GLP-1 have stopped using it within a year. Another study showed 85% of individuals who newly started GLP-1s for weight loss were no longer taking the drug after two years. This leaves patients and payers to manage the consequences of weight regain once the medications are discontinued. Some patients will tolerate side effects better than others, and some side effects, like gastroparesis can be dangerous and costly to manage. Every patient deserves a choice including GLP-1 off-ramps and/or non-medication alternatives.

The Role of Lifestyle Programs in GLP-1 Prescribing / Deprescribing

Should coverage for GLP-1s for obesity depend on participation in a lifestyle program that supports behavior modification, nutrition, and education?  

This powerful class of drugs were not approved by the FDA to be taken without lifestyle change. We also know that lifestyle change can be hard for people to achieve on their own, so pairing coverage with lifestyle modification support is critical to achieve results. The question then becomes, “what is the right program or support to accompany the medication?” 

From Virta’s perspective, GLP-1 medications would ideally be used as an adjunct to a validated, effective, and sustainable lifestyle and nutritional intervention. In addition, we believe it is critical to engage in shared decision making with members and assess their readiness for change, with the goal of steering them into the right combination of lifestyle change and/or medication, depending on their specific needs, goals and preferences.   

Should employers and health plans expect their members to be on these medications for life once started, or is safe deprescription with sustained outcomes possible?

Virta makes successful deprescription from GLP-1s possible, as published in the first known peer-reviewed study demonstrating 85% weight loss sustained one year after stopping a GLP-1.³

Virta offers a flexible, proven, member-centric approach to losing weight, and managing GLP-1 utilization and spend. 

Virta’s nutrition-first therapy approach provides a pathway for each member’s unique needs and goals, and can be a highly effective GLP-1 alternative, co-therapy or sustainable off-ramp.