Sara Izadi, PharmD
You may have recently heard of some new magic weight loss drugs, Ozempic® (semaglutide) and Mounjaro® (terzepatide). Mentions of these injectables exploded on social media in 2022, and early ’23 is no different. At the Oscars, host Jimmy Kimmel decided the stars were aligned – pun intended – for a weight loss joke during his monologue. While the audience seemed to appreciate Kimmel’s wit genuinely, this is no laughing matter.
Yes, a four-week treatment course of Ozempic or Mounjaro can help you reach a goal weight and trim inches off your waist. The problem, however, is multifaceted. Ozempic and Mounjaro are drugs in the glucagon-like-peptide-1 (GLP-1) receptor agonist drug class. These two drugs are approved for the treatment of type-2 diabetes. Because they also help with weight loss, off-label use became popular with celebrities that could afford them and wanted to shed some pounds.
Are all GLP-1s approved for weight loss?
Today, there are only two GLP-1 agonists approved by the Food and Drug Administration (FDA) for obesity - Wegovy® (semaglutide) and Saxenda® (Liraglutide). There are five more FDA-approved GLP-1s, including Ozempic. Additional approvals are expected, but none of the others have weight loss on their label at this time, and Ozempic and Wegovy are officially in short supply.
Additionally, healthcare consumers no longer need to go to a specialist or their primary care provider’s office to get a prescription. For example, people can receive treatment from local medical spas, and there are even Groupons out there for discounted treatment using GLP-1s!
Also, it’s concerning that some consumers are taking matters into their own hands and seeking compounded medication to help them lose weight. Last I checked, these commercially available GLP-1s should not be compounded.
Why is a Pharmacy Benefit Manager (PBM) commenting on this?
With projections indicating that over 50% of the population will be obese by 20301, more FDA approvals of GLP-1s for obesity coming our way, and the social media craze, the pharmacy costs associated with GLP-1s are expected to skyrocket. And Wegovy’s list price is already roughly $1,350 per month.
What are GLP-1s, and should they be considered for obesity?
GLP-1s work by mimicking a gut hormone, which stimulates insulin release from the pancreas to lower blood sugar levels2. A major side effect of this class of drugs is rapid weight loss. Once the broader market realized this, demand started to rise from individuals who may not be candidates for the drug. Thus the rapid spread of social media coverage touting the drug’s effects and off-label use for weight loss.
Outside of diabetes, healthcare professionals may prescribe GLP-1s to people 1) suffering from obesity or 2) who are overweight and have at least one weight-related health condition (e.g., high blood pressure or heart disease). Typically, these medications should only be prescribed after someone has tried other weight loss methods, such as diet and exercise, without success. Despite the recommendations, there is widespread use of these drugs by patients who do not meet these criteria.
GLP-1s are clearly an effective way to help patients lose weight, so they should be considered for obesity; however, the incremental demand has contributed to the previously mentioned supply chain problems where individuals with diabetes or those who meet the criteria for weight loss are unable to get the medications they need.
What side effects of GLP-1s should be considered?
Ozempic’s rise to fame is shrouded in controversy not only because those who truly need the medication may not be able to get it but also because the weight loss side effect may not be long-lasting, and there might be serious complications down the line.
Long-term side effects of the drug may include gastrointestinal damage, gallstone issues, and urinary tract infections. These and other potentially dangerous complications3 should be considered case-by-case by trained medical professionals. In addition, patients tend to regain weight if the medication is stopped4.
What is Capital Rx doing to manage this problem currently?
Capital Rx’s goal is to ensure that members who are true candidates for GLP-1s have access to these treatments.
Prior authorization (PA) is necessary for GLP-1s.
Prescribers that recommend GLP-1s for patients that are Capital Rx members must submit a PA request for a medical necessity review. The PA process involves a clinician’s review to ensure members meet the requirements and are being prescribed a GLP-1 according to national guidelines. We don’t like that a review is required, but given the liberal, often inappropriate use of these medications, there’s no better way to address the issue at this time.
Can Capital Rx help reduce the cost of GLP-1s for plan sponsors long-term?
Unfortunately, given the increasing incidence of obesity and demand for weight loss solutions, I can see the potential for plan sponsors’ spend – Rx + medical – to rise by 5%+ from the use of GLP-1s alone5.
Capital Rx is exploring opportunities to collaborate and partner with clinical weight loss solutions offering a multidisciplinary weight loss management approach. JUDI®, our Enterprise Pharmacy Platform, allows seamless integration with such point solutions. JUDI also allows us to implement various strategies to reduce the utilization of GLP-1s where appropriate.
For example, strategies may include leveraging JUDI’s smart step technology to ensure that a member “steps through” a clinical weight loss program before being able to fill a GLP-1 prescription, targeting a member that has been prescribed a GLP-1 to ensure they are also enrolled in a weight loss program, or leveraging JUDI’s plan design features to offer members incentives to take advantage of clinical weight loss solutions.
In summary…
Obesity is one of the more costly diseases for health plans; adults with obesity are estimated to have over $170 billion in excess annual medical costs6. And GLP-1s have become the “drug of choice” for many Americans seeking a weight loss solution.
When GLP-1s are used to treat obesity and diabetes, prescription drug costs may rise in the near term, but total medical costs should fall in the long run. As these drugs are used inappropriately for “vanity” reasons, plan sponsors are considering cost, value, and risks - i.e., thinking twice about coverage and the cost-benefit. And if the use case is for cosmetic purposes, plan sponsors will likely treat GLP-1s like hair loss or anti-wrinkle products, which are often excluded from coverage.
A combination of responsible clinical programs and technology is needed to provide better access to GLP-1s for appropriate uses. But there’s no “easy button.” Technology alone can’t streamline the workflow and solve the friction created by the uptick in demand for GLP-1s.
Contact us if you’d like to learn more about Capital Rx’s Clinical Programs or full-service Pharmacy Benefit Solutions.
1 Ward, Z. J. et al. Projected U.S. State-Level Prevalence of Adult Obesity and Severe Obesity. N. Engl. J. Med. 381, 2440–2450. (2019).
2 Shaefer CF Jr, Kushner P, Aguilar R. User's guide to mechanism of action and clinical use of GLP-1 receptor agonists. Postgrad Med. 2015;127(8):818-26. doi: 10.1080/00325481.2015.1090295. Epub 2015 Sep 15. PMID: 26371721.
3 Filippatos TD, Panagiotopoulou TV, Elisaf MS. Adverse Effects of GLP-1 Receptor Agonists. Rev Diabet Stud. 2014 Fall-Winter;11(3-4):202-30. doi: 10.1900/RDS.2014.11.202. Epub 2015 Feb 10. PMID: 26177483; PMCID: PMC5397288.
4 Caro, Rebecca DO; Samsel, David MD; Savel, Paul MD. Is there sustained weight loss after discontinuation of GLP-1 agonist for obesity treatment?. Evidence-Based Practice ():10.1097/EBP.0000000000001786. doi: 10.1097/EBP.0000000000001786. 2022 Oct 12.
5 Virta Health Webinar: Is America’s Future Obesity Free? 2021 June 17.
6 Ward ZJ, Bleich SN, Long MW, Gortmaker SL. Association of body mass index with health care expenditures in the United States by age and sex. PLoS One. 2021 Mar 24;16(3):e0247307. doi: 10.1371/journal.pone.0247307. PMID: 33760880; PMCID: PMC7990296.