The emergence of seemingly miraculous drugs to treat chronic or specialty conditions – usually with very high price tags – has become a trend in the pharmaceutical landscape. The latest such drug class is GLP-1s, initially approved for the treatment of type 2 diabetes, although some have since been approved to treat cardiovascular disease.

While these treatments are very effective at treating type 2 diabetes, they are also extremely expensive. These drugs work to reduce blood sugar levels results in weight loss, making them an attractive option for those without diabetes looking to lose weight. Indeed, some drug manufacturers are using social media, TV, and other direct-to-consumer marketing tactics, such as drug coupons, to increase utilization and boost their profits.

This poses a challenge for employers trying to offer robust, sustainable benefits to their employees at an affordable cost to the plan and members. Consider that:

Much of that growth is expected to be fueled by novel and high-cost drugs in a select few categories, and GLP-1s are among them. In fact, nearly 700,000 new GLP-1 prescriptions were written in just one month – February 2024 – according to a national drug trend report. That is an astounding 181% increase compared to two years ago.

While these drugs and their associated costs increase the health care burden and pose a challenge for our plan sponsors, it is particularly concerning for small- to mid-sized self-funded plans. Just a few members newly starting on the drug can significantly impact the plan’s annual cost. Not surprising, then, that many employers are choosing to cover GLP-1s for diabetes but exclude them for weight loss. Among RxBenefits clients, about 75% of plans have adopted this approach to help balance controlling plan costs and member access. This is part of a plan’s formulary management approach and is the first step in combatting off-label use.

However, the challenge is ensuring that prescriptions that are being filled are for patients with a diagnosis of diabetes and preventing inappropriate use. Left unchecked, an estimated 40% of GLP-1 prescriptions could be for off-label use.

Employers can’t afford to pay for drugs prescribed inappropriately, and members with type 2 diabetes can’t afford to go without the appropriately prescribed drugs they need. Protecting them both requires expert utilization management, including programs like prior authorizations (PA), quantity limits, and step therapy. Automated prior authorization processes used by the ‘Big Three’ pharmacy benefit managers – and many others – can miss these prescriptions, negatively impacting employer plan costs and members.

At RxBenefits, we continually monitor drug trends and develop innovative solutions to mitigate their impact on self-funded plans.

In 2023, we began noticing a rise in GLP-1 prescriptions and a growing impact on plan costs. RxBenefits’ Protect suite of clinical solutions helps employers ensure the safety and necessity of their members’ prescriptions with all existing PA, step therapy, and quantity limit programs as well as with a new enhancement to take on the rising GLP-1 challenge – utilization management for the next generation of diabetes drugs.

This expansion to our utilization management solution automatically flags GLP-1 claims – for the lower-dose version of the drugs – for prior authorization, requiring the prescriber to confirm that the prescription is medically necessary and dosed according to FDA guidelines. If those criteria are not met, the PA is not approved.

GLP-1s aren’t going anywhere – nor should they, as they’re shown to work well for patients who need them for type 2 diabetes and for the complications that can come with being overweight. But it’s crucial that diabetes patients be able to access the drugs they need, and it’s crucial that employers know their members and their plan are both protected from the harms that come with inappropriate prescribing.

Every prescription benefits plan can benefit from layers of protection. Adding utilization management solutions like RxBenefits Protect – and its targeted GLP-1 enhancement – provides the security employers need to feel safe about the health of their plan and their members.

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