As insurers struggle with GLP-1 drug costs, some seek to wean patients off

By Jamie Ducharme KFF Medical News After losing pounds on the injectable weight loss medication Zepbound Kyra Wensley received a surprising letter from her pharmacy benefit manager in April Her request for coverage had been denied the letter noted because she d had a body mass index of less than when she started Zepbound The -year-old who lives in New York had been taking Zepbound without situation for months so she was confused Why was her BMI which had been around when she started becoming an issue only now Wensley had no interest in quitting an effective drug Going right off like that it s easier noted than done she revealed Her healthcare provider fought to keep her on the GLP- agonist the category that includes weight loss and Type diabetes drugs Ozempic Wegovy Mounjaro and Zepbound But Wensley ultimately had to switch from Zepbound to Wegovy to meet her plan s requirements She commented she doesn t like Wegovy as much as her old medication but she now feels lucky to be on any GLP- Kyra Wensley s medical expert fought to keep her on the injectable weight loss medication Zepbound but Wensley ultimately had to switch to Wegovy a different GLP- agonist to meet her physical condition plan s requirements Lori Wensley KFF STRENGTH TNS Lots of research suggests such medications must be used indefinitely to maintain weight loss and related strength benefits But with list prices of roughly a month community and private payers are struggling to keep up with ballooning demand for GLP- weight loss drugs and in specific cases are eliminating or restricting their coverage as a product North Carolina Medicaid plans to end GLP- coverage for weight loss on Oct just over a year after starting the coverage Pennsylvania is planning to limit Medicaid coverage to beneficiaries at the highest hazard of complications from obesity And despite contemporary reports of a likely federal pilot effort to extend coverage of GLP- obesity drugs under Medicaid and Medicare all state Medicaid programs are likely to be under pressure due to steep spending cuts in the budget reconciliation package lately signed into law by President Donald Trump Already a multitude of GLP- users quit within a year studies suggest often due to side effects high costs or insurance issues Now a growing number of researchers payers and providers are exploring deliberate deprescription which aims to taper specific patients off their medication after they have taken it for a certain amount of time or lost a certain amount of weight The U K s National Institute for Wellness and Care Excellence which creates guidance for the National Wellbeing Organization recommends two-year limits on the use of selected weight loss medications such as Wegovy And the concept was raised in a latest Institute for Clinical and Economic Review review on affordable access to obesity drugs A Mark Fendrick who directs the Center for Value-Based Insurance Design at the University of Michigan has argued that if particular people using GLP- s to lose weight were eventually transitioned off more people could take advantage of them If you re going to spend billion or billion you could either spend it on fewer people for a long period of time or you can spend it on a lot more people for a shorter period of time he mentioned Fendrick s employer the University of Michigan indeed does that Its prescription drug plan caps coverage of GLP- drugs at two years if they re used solely for weight loss Jamie Bennett a spokesperson for Wegovy and Ozempic maker Novo Nordisk declined to comment on the concept of deprescription noting that its drugs are intended for chronic conditions Rachel Sorvig a spokesperson for Zepbound and Mounjaro manufacturer Eli Lilly declared in a announcement that users should talk to their robustness care provider about dosage and duration demands Studies have shown that people typically regain a substantial amount of weight within a year of stopping GLP- medications and that plenty of people who quit ultimately go back on the drugs There s no standard of care or gold standard on how to wean right now reported Allison Adams an obesity and internal medicine specialist with UK HealthCare in Kentucky But the math shows why time-limited coverage is appealing to payers that struggle to pay for beneficiaries GLP- prescriptions reported Michelle Gourdine chief anatomical officer for the pharmacy benefit manager CVS Caremark And states are between a rock and a hard place explained Kody Kinsley who until January led North Carolina s Fitness and Human Services Department They re going to have to look at every single thing and trim dollars everywhere they can Pennsylvania was looking for cost-saving strategies even before the new federal tax-and-spending law according to Brandon Cwalina press secretary for the state s Department of Human Services Pennsylvania projects it will spend billion on GLP- drugs this year Related Articles States are taking strategies to ease access to COVID- vaccines as they await federal recommendation Plenty of Black Latino people can t get opioid addiction med Medicaid cuts may make it harder West Nile virus cases running higher than normal prompting robustness warnings Barry Sanders advocates for people to know their cholesterol numbers a year after his heart attack Strokes can cause debilitating damage Two UConn researchers have ascertained a way to limit it Plans could see real savings Fendrick explained if they covered GLP- s for initial weight loss then moved people to cheaper options such as more affordable drugs or behavioral medical programs to maintain it Plenty of companies are eager to sell insurers employers and individuals on behavioral alternatives One is Virta Robustness which advertises its nutrition-focused weight management plan as a proven approach for deprescribing GLP- s when clinically appropriate A Virta-funded research assessed people with Type diabetes who stopped using GLP- medications but continued following Virta s venture concluding that their weight did not significantly increase after a year Researchers affiliated with a European weight management company also in recent months informed that slowly tapering off the medications may help maintain weight loss For employers and insurers the initial question was whether to cover GLP- s for obesity noted Virta CEO Sami Inkinen Now basically everyone s coming to the middle and asking How do we responsibly cover these drugs Part of responsible coverage Inkinen declared is providing other forms of help to patients who stop using GLP- medications by choice or otherwise For a few people however maintaining weight loss without a GLP- remains a challenge even with other options available Lily who lives in Michigan lost almost pounds in roughly months on Wegovy But she had to quit the drug when she turned and left her parents insurance plan this year The plan her employer offers stopped covering GLP- s for weight loss right around the time she joined Lily who sought to be identified by only her first name because she is not out to her family as transgender has tried other medications since then and previously tried lifestyle programs to control her weight But she disclosed nothing works as well for her as Wegovy She has regained pounds since going off the drug at the beginning of the year and worries that number will continue to rise potentially contributing to future robustness problems Just give people the drugs she mentioned It seems cheaper and safer in the long run KFF Medical News Distributed by Tribune Content Agency LLC