Health Care

PBMs, insurers restrict Ozempic, Wegovy, weight loss drug access

Nine of the 17 largest insurers have restrictions beyond the FDA’s label, the analysis found. Before paying for the drug, several Blue Cross Blue Shield insurers, for example, require patients to complete rigorous exercise and diet programs that promise to help them lose at least one pound per week over a three-month period, the analysis said. 

“The higher the cost of the drug, the more likely health plans will restrict it. The higher the prevalence of the disease, controlling for other factors, the more likely health plans will be restrictive,” said James Chambers, an associate professor at Tufts Medical Center. 

Centene and Highmark Health are the only insurers studied that developed policies in line with what the FDA’s label indicates, so long as patients use Wegovy in conjunction with exercise and diet programs, the analysis found. 

Highmark met with local providers to discuss the patient population and prescribing habits, and decided to maintain its coverage policy for Wegovy. “The [return-on-investment] on spending $13,000 a year on a diabetic to keep them from having cardiovascular problems is a drop in the bucket,” said Dr. Tim Law, Highmark’s vice president and executive medical director. “It’s minuscule compared to the cost of care if you don’t treat these people, as well as those with obesity problems.” 

Centene did not respond to an interview request.  

Drugmakers know they do not need insurance coverage to sell the drugs. Doctors wrote more than 500,000 new prescriptions for GLP-1s in February, up 152% from a year ago, according to a report issued this month from drug analytics firm IQVIA. Insurers, employers and patients spent $2.1 billion on the products in 2022, the report said. 

“You’re going to have a lot of folks who do not meet the stringent criteria that insurers architect in order for them to get coverage,” Ciaccia said. “This is one where I think the consumer, if they have the financial wherewithal, will be willing to stretch in order to pay for it out-of-pocket.” 

At their current price, Wegovy and other GLP-1 drugs do not deliver an affordable long-term value for 99.9% of the eligible population, according to an October report from the Institute for Clinical and Economic Review. Drug manufacturers would need to cut their prices by almost half to ensure they are a good value for most patients, acording to the report.

Novo Nordisk has pricing plans available for insured patients with high cost-sharing requirements, or those paying cash for the drug, a spokesperson wrote in an email. Approximately 40 million individuals with obesity have commercial coverage for Wegovy, the spokesperson wrote. Commercial insurers are using pharmacy benefit managers to limit patients’ access to anti-obesity medications by requiring employers to opt-in to coverage, the spokesperson said. 

PBMs are not recommending employers pay for their workers to use these drugs, the spokesperson said. 

Most employers are not interested in adding GLP-1s to their formularies, Cigna Group CEO David Cordani said during the company’s first-quarter earnings call last week. Cigna is one of the largest administrators of job-based insurance, helping companies develop and enforce coverage policies for 16 million workers. The insurer, which also operates the large pharmacy benefit manager Express Scripts, has inked value-based payment plans with GLP-1 drug manufacturers to control the cost of the drugs, Cordani said. Cigna did not respond to an interview request. 

“Employers have had a more limited appetite to expand coverage beyond clinical diagnoses, such as diabetes, for certain lifestyle treatments,” Cordani said on the earnings call. “There has been some, but we’ve seen more limited adoption of that, thus far.”  

Insurers like Cigna stand to make money from the drugs by dispensing them from pharmacies owned by the same parent organization, Ciaccia said. Payers can also generate revenue by retaining rebates from drug manufacturers, he said. Any additional costs carriers incur will be passed down to consumers as higher premiums, he said. “There are a number of ways that they could find to get their own slice of the pie,” Ciaccia said. 

Norfleet’s experience reflects the hesitancy payers have adopting the drugs, and the restrictions they have placed on them. OptumRx denied his second prior authorization request for Wegovy in early February. “Based on the information provided, the member did not meet the medication-specific, clinical evidence-based guidelines for Wegovy,” an OptumRx spokesperson wrote in an email to Modern Healthcare.

Norfleet said he called OptumRx to tell the company that their prior authorization system improperly rejected his claim. But after getting nowhere with the PBM’s call center staff, Norfleet turned to Twitter to get his denial overturned. He said it was only then that he was able to successfully appeal OptumRx’s prior authorization decision and fill his prescription for Wegovy. 

“It’s been a life changer,” Norfleet said of the drug. “Now that my weight has dropped down, I don’t need equipment, I don’t wake up having difficulty breathing in the middle of the night anymore. It’s been a game-changer for me.”

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