The “Skinny” on Weight Loss Drugs

November 2023
A lot of attention has been given lately to a new class of drugs called GLP-1’s. These drugs are increasingly being prescribed for type 2 diabetes and weight loss. Most Crystal Clear Rx clients cover these drugs for diabetes, but more and more Plan Sponsors are asking whether they should also cover these drugs for weight loss?

Obesity is a real problem in the U.S. today. According to the CDC, over 40% of American adults are obese. Obesity contributes to many health-related conditions such as type 2 diabetes, cardiovascular disease, stroke, musculoskeletal disorders and so on. These conditions drive pharmacy and medical costs for Plan Sponsors. Therefore, it makes perfect sense for Plans to consider what they can do to help their members control and maintain a healthy weight.

Many Plans currently only cover these drugs for members who are already using other, diabetic products. In other words, the Plan covers these drugs only for people diagnosed with diabetes. But does it make sense to cover these drugs for obesity? At an average cost of around $1,000 per month, this therapy is not inexpensive. So, will the Plan realize any financial benefits for covering the cost of these drugs?

Studies are showing significant health improvements for patients who have lost weight due to the use of a GLP-1 drug. These studies also report that there are some minor side-effects that can be troublesome but are generally controllable. There is a very slight risk of more serious side-effects, but these are rare. In discussing this with some industry experts, we expect to see a continued increase in the prescribing of these drugs as time goes on, and as more and more data continues to show very positive results from these products.

Data shows that patients who are prescribed a GLP-1 drug can lose 15-20% of their body weight, or even more in some cases. However, some sources report that these drugs do not work for everyone. And there is some data that shows that once patients discontinue taking these drugs, they often regain all the weight they previously lost. Lifestyle changes remain an important necessity in maintaining a healthy weight, and relying solely on a drug for positive results is not ideal.

So, should CCRx clients begin covering GLP-1 medications for the treatment of obesity? This may cause an increase in Rx costs initially, but in the longer term we hope and expect to see a reduction in both pharmacy and medical costs for diabetes and other weight-related conditions.

We expect more and more pressure on Plans to begin covering these medications. Plans may want to establish certain criteria that must be met to get approval from the Plan to cover these drugs. For example, some plans will only cover these drugs for the indication of weight loss if the member has a BMI of 30 or above, or 27 and above in combination with a serious, health risk such as high blood pressure, or high cholesterol. The Plan may also wish to require continued weight loss over time as a criterion for ongoing coverage of the product.

If you have questions about weight loss drugs or would like our help in developing Prior Authorization criteria to manage these products, please contact your CCRx Consultant.