There is growing attention on the GLP-1 category for the treatment of weight loss. Saxenda (liraglutide), Wegovy (semaglutide) and Mounjaro (tirzepatide) are three products in the category approved by the US Food and Drug Administration for the treatment of weight loss.  This article provides the payer landscape for the category which looks at both how Pharmacy Benefit Manager (PBM) formularies and twenty large employer sponsored commercial benefits treat these therapeutics.

It is necessary to review both whether a PBM’s formulary includes a therapeutic and if a plan sponsor’s benefit covers the weight loss category.  Having both pieces of information is necessary to understand if patients have access to these products.  In other words, a PBM’s formulary may include a product but if the benefit excludes the category that a product is in, patients will not have access to the product since it is considered excluded under benefit.  The converse is also true a benefit may cover a category such as weight loss medication but if a particular product is not covered on the formulary the patient will not have access to that product.

PBM National Formulary Inclusion

A review of PBM national formularies for 2022 was conducted and as of that time the three major PBMs, CVS, Express Scripts and OptumRx, have taken divergent formulary strategies with respect to the GLP-1 agents indicated for weight loss. The formularies supported by CVS largely have open access. Express Scripts supported formularies have put up barriers to access. OptumRx supported formularies too have limited access.  These differences mean prescribers and patients depending on a patient’s benefit will not only have to consider the clinical merits of going on these therapies but also consider which pharmacy benefit manager administers the benefit as it determines which formulary a patient’s pharmacy benefit is tied to.

Large Employer Group Benefit Coverage

As mentioned, understanding the formulary standing of products is necessary but not sufficient in determining access to the GLP-1s.  The benefit structure must also be in alignment for a patient to have access to these products.  Looking at a sample of large employer group benefit documents – summary of benefits and evidence of coverage – over time it is observed that employer sponsored health benefits have opened up to coverage of weight loss treatments not limited to GLP-1s. That is it is likely one in twenty employer groups in 2016, two in twenty employer groups in 2019, three in twenty employer groups in 2021 employers covered weight loss drugs. Last year two additional large US employers benefits bringing the current total of large employers to likely five in twenty in 2022. Based on an inference-based approach where if bariatric surgery was covered it could be inferred that coverage of weight loss therapeutics was also included.

Commercial Market Access Coverage Analysis

Taking the above-mentioned findings and integrating the PBM formularies with the plan sponsor benefits it is estimated that 20 of the largest corporations combined have 6.5M US employees. Of the 6.5M employees, 3.6M are subscribers to their employer’s sponsored health plans. With their dependents it is estimated that they compose 7.6M health plan members in the US. Within that membership it is estimated 3.2M have a BMI ≥ 30. Based on the formularies and benefits reviewed 0.8M (27%) of the 3.2M health plan members currently have fairly unhindered formulary access to the treatments, Saxenda, Wegovy and Mounjaro.

*The 20 large employer groups evaluated include: Walmart, Inc., Amazon.com, Inc., Allied Universal, Accenture, FedEx Corporation, Home Depot, Yum! Brands, Kroger, Berkshire Hathaway, IBM, United Parcel Service, Target Corporation, DHL, Starbucks, Ernst & Young, UnitedHealth Group, Deloitte, Cognizant Technology Solutions, CVS Health, Walgreens Boots Alliance

Written By:

Andrew Levine, PharmD FAHM