Cigna’s Copay Caps Add to Growing Suite of Solutions to GLP-1 Cost Concerns

In an effort to help employers meet the “growing demand” for weight loss medications, The Cigna Group’s Evernorth Health Services on May 21 announced a deal with Eli Lilly and Co. and Novo Nordisk to cap Zepbound (tirzepatide) and Wegovy (semaglutide) copays at $200 per month for plan members, saving them as much as $3,600 per year compared to buying the weight loss medications directly from manufacturers. Employers will also see a lower net cost for the drug, Evernorth said. That could be an attractive option for firms that are still considering the many tradeoffs associated with deciding how to cover GLP-1s. “What we’re seeing is a lot of panic, confusion and some degree of frustration from plan sponsors because their members want [GLP-1s] and [employers] don’t know that they can afford to carry them,” Scripta Insights CEO Eric Levin tells AIS Health, a division of MMIT. “They’re trying to figure out how to deal with this disconnect between member need and the ability to pay for it.” Some major managed care firms are trying to keep costs down for clients by preferring certain agents. CVS Health Corp., for example, recently decided to favor Wegovy over Zepbound on the largest commercial template formularies for its Caremark PBM beginning July 1. While CVS said the move will increase GLP-1 access, it could also cause stress for providers and patients who take a different GLP-1 and must start again with an alternative drug. “From the doctor’s perspective, what’s the best way to do that? What are the potential complications?” asks Levin, whose company provides pharmacy benefit navigation to employer plan members. “There’s a lot going on in terms of coverage that is happening quickly that I think is causing a lot of stress for plan sponsors.” One line of defense employers might try is utilization management (UM) to limit who can use the drugs and under which criteria. However, UM strategies can influence the level of rebates a manufacturer is willing to offer. “The more utilization management you add, the more expensive the drug becomes,” Levin explains. “So now you’re kind of stuck in terms of trying to figure out coverage.” This makes budgeting for GLP-1s even more difficult. “You really have to weigh how much utilization costs are going to be versus the unit costs that go up as you increase prior authorizations and you increase what’s required in order to be approved under the plan for this,” said Ferrin Williams, Scripta’s chief pharmacy officer, during a May 21 webinar hosted by the company. “If you’re getting one unit price and you’re doing your budget, but then you’re implementing UM guidelines, it’s not going to be one to one [pricing].” There are a few ways plan sponsors can control costs of GLP-1s. One way is to remember that plan forecasting doesn’t equal real member behavior, Williams said. In other words, GLP-1s are not drugs that a physician can prescribe with 12 months of refills and no follow-up until the following year. Regular follow-up is needed to adjust the dosage and ensure the medication is working. “[Patients] are changing therapies as they’re dealing with side effects, as they’re dealing with cost issues and as they deal with demand issues,” Williams explained. Plan sponsors should work with their consultants to ensure they are not treating GLP-1s like other drugs during budget forecasting, she added. Another tactic is decentralization, where employers offer cost savings programs that fall outside the traditional benefits. Cash pay programs are a “hot topic,” Williams said, giving the example of RxSaveCard. Employers fund a certain amount of money on the card each month. When used at the pharmacy counter, it calculates the lowest cost among several discount cards, ensuring the lowest price. The card program offers options for GLP-1s. “Making sure that you’re able to have choices and options and that you know all those options as a plan sponsor, like cash pay programs, will help your members,” Williams said. “[Cash pay programs] can ensure you have coverage.” Buying Guides Can Help Patients Navigate Choices “If necessity’s the mother of invention, we’re seeing invention out of necessity here [in the GLP-1 space],” Levin tells AIS Health. “We’re seeing plan sponsors and companies try to find a way to make GLP-1s affordable and get them to plan members.” Buying guides are one way to help plan members find the best options. Recently, Scripta rolled out its GLP-1 Navigator, a guide for Scripta member plans that is geared toward companies that don’t cover the drugs. The idea was born when Levin tried to help a relative who was struggling to make sense of the brand options and payment plans for GLP-1s. While seeking the information himself, Levin realized the complexity involved and sought to put the information together in one place. The GLP-1 Navigator includes information on brand and formulation differences (including branded vs. compounded formulas), side effects, cash pay vs. insurance, and information on how to compare vendors, suppliers and prices. It also answers questions users may have on issues such as the difference between auto-injector pens and syringes. “Fundamentally, when we think about comparison shopping, we generally think, ‘Which drug am I going to take? Where am I going to buy it? Is there a discount card or coupon available that could help me save money on it?’” Levin says. “And those three variables are very much linked — they’re not mutually exclusive.” The navigator also walks users through whether they want or need clinical weight loss support along with the medication. “We really try to walk them through each of the variables in the journey. Then once they’ve found the category they think best fits them, then what we try to do is present the couple of top options that we found that might be able to meet their needs and provide links to purchase those,” Levin explains. The navigator is another tool employers can use to help members obtain GLP-1s even if the employer cannot cover them. “We know that plan sponsors have benefits to attract talent, retain talent and keep people healthy and coming to work,” Levin said during the webinar. “And if there's this much demand and you're sort of making your members unhappy, that's going to have consequences beyond just even the cost of the drugs themselves. And so that's really where the thought process was behind.”