The inside scoop on GLP-I weight loss drugs

The Federal Drug Administration recently approved a new drug for weight loss, Zepbound (tirzepatide), manufactured by Eli Lilly. This ingredient may sound familiar- it’s the same medication that is present in Mounjaro, a diabetes medication for type 2 diabetes that has been associated with significant weight loss, generating a lot of attention in the media, in healthcare and on social networks. These drugs are creating excitement because they offer the possibility of dramatic weight loss and type 2 reversal without bariatric surgery.

Diabetes and obesity are epidemic in the United States. The Centers for Disease Control and Prevention (CDC) reports that diabetes affects 38.4 million adults, 11.6% of the population. At least 90% of those have type 2 diabetes, which is associated with weight gain. That includes an estimated 8.7 million who are undiagnosed. Another 97.6 million adults have prediabetes, a reversible precursor to the disease. And nearly 42% of American adults are obese, up from 30.5% in 2000. Obesity costs the nation about $173 billion annually, with medical costs for obese adults $1,861 higher than for adults with healthy weight. According to the Arkansas Center for Health Improvements, Arkansas ranks 6^th among the nation’s worst states for obesity.

Finding new approaches to treating and preventing diabetes and obesity are top priorities for health and economic reasons. And GLP-1 drugs show great promise.

What are GLP-1 drugs?

This group of drugs are known as Glucagon-Like Peptide-1 receptor agonists, or GLP-1 drugs. Besides Zepbound, this class also includes Ozempic, Wegovy, Rybelsus, Victoza, Saxenda, Mounjaro and Trulicity.

Wendy See, vice president of primary care and pharmacy programs for Arkansas Blue Cross and Blue Shield, said this class of drugs have been around more than a decade, but that FDA approval for Wegovy for weight loss in 2021 kickstarted a dramatic uptick in prescriptions as well as questions from members. “There’s a lot of confusion about how these drugs work, how safe and effective they are, and what is covered,” See said. “We’re working to make sure the right patients get the right meds for their conditions.”

See, a pharmacist, said Ozempic, Wegovy and Rybelsus have the same chemical makeup, semaglutide, though Rybelsus is in the form of a daily tablet instead of a weekly injection. They’re all made by the same manufacturer, Novo Nordisk. Ozempic and Rybelsus are indicated for type 2 diabetes only, while Wegovy is approved for weight loss.

Likewise, Zepbound and Mounjaro are the same chemical compound, tirzepatide, made by Eli Lilly. Mounjaro treats type 2 diabetes and Zepbound is now available for weight loss in obese and overweight patients with a weight-related chronic condition. Victoza for type 2 diabetes and Saxenda for weight loss are also the same drug, liraglutide (made by Novo Nordisk), while the older diabetes drug Trulicity (dulaglutide) is another product from Eli Lilly. See said more drugs in this class are in the FDA pipeline and may be approved in coming years.

How they work

GLP-1 drugs mimic hormones that are naturally released after a meal. They increase insulin discharge from the pancreas while also reducing release of glucagon, a hunger hormone. They decrease patients’ appetites and may make them queasier while delaying digestion and causing them to feel fuller longer.

“Ozempic, for instance, is typically a perpetual medicine for type 2 diabetes patients. It helps decrease their weight, which in itself helps the condition, but it also lowers their glucose and A1C. Certain patients can achieve a full reversal of their diabetes with Ozempic. It’s expensive, but effective,” See said.

Side effects and abandonment rates

Currently, the list price for drugs in this class can be as much as $1,300 per month before insurance. See explained that for sustained weight loss, patients need to stay on GLP-1 drugs indefinitely; when they stop taking the drug, they quickly rebound and regain their weight.

Wegovy is more expensive than Ozempic, even without insurance, because to achieve significant weight loss, it is prescribed at higher doses.

The side effects profile of GLP-1 drugs can be quite severe, See said, especially at the dosage levels required for weight loss. To name a few, side effects can include severe diarrhea, abdominal cramping, nausea and vomiting; anaphylaxis and angioedema; acute renal injury; pancreatitis; gastroparesis; and increased risk of thyroid cancer, particularly Medullary Thyroid Carcinoma (MTC). Long-term effects are largely yet to be established.

“Some articles I’ve read based on real-world claims information show that fewer than 30% of patients taking Wegovy are still on it 12 months later,” See said, explaining that the harsh side effects lead to high abandonment rates. “So, the investment that the patient and their payer make can be counted as a waste if the patient drops off the medication and regains the weight.”

Coverage and costs

Goodroot, a conglomeration of companies working to improve healthcare, published a  guide to GLP-1 products for weight loss. Their guide says that only 25% of health plans cover weight-loss medications with prior authorization, and 10% to 15% of plans allow coverage without it. Medicare currently does not cover these medications for weight loss, but also has not made a definitive decision about them.

See said most commercial insurance plans, including Arkansas Blue Cross and Health Advantage health plans, do not cover weight-loss medications, but do cover GLP-1 drugs for treating type 2 diabetes. However, knowing this, there’s been a spike in providers writing scripts for Ozempic intended for weight loss in people who do not have type 2 diabetes. These claims for of-label uses are not eligible for approval.

Sometimes manufacturer coupons greatly reduce the cost for patients, but See notes that eventually all coupons run out, leaving the patient to foot the entire bill.

“It will be interesting to watch how Zepbound compares to Wegovy, and if the costs will decrease now that Novo Nordisk has more competition in the weight-loss space,” See said. “There’s definitely going to be even more interest and attention paid to these medications now, both in terms of their safety and efficacy and how to make them more affordable.”

Better together

See said that a spike in claims in the past year show that more providers are using the new GLP-1 drugs as a first-line treatment for type 2 diabetes, instead of starting with the evidence-based traditional regimens such as metformin along with diet and exercise programs. Providers are now also more likely to prescribe the GLP-1 drugs for weight loss, relying on these new medicines alone to cure obesity.

In a June article published by Fierce Healthcare, Randy Vogenberg, a nationally known expert on pharmacy and healthcare insurance issues, wrote in an email, “Generally, the goal is to couple any use of this drug category for weight loss within their existing integrated plan offerings. Having counseling, support groups, and regular medical check-ups are all part of the options in effectively achieving then sustaining weight loss.”

He added that there have been reports of medical problems after one or two years of using the medications. “There remains a lot to learn and know about these drugs, so it is a concern of employers, not just financial, but the health and well-being of their covered members.”

Payer models for weight-loss medications

See said insurers across the country are exploring ways to responsibly cover weight-loss medications. Among the options are requiring prior authorization, step therapy or combination therapy. Step therapy might require patients begin with a weight management program before receiving a GLP-1 prescription, while combination therapy would pair the GLP-1 prescription with other weight management program elements.

A higher member cost-share for weight-loss GLP-1 drugs is also a possibility. According to See, another option under review is offering groups riders or supplemental coverage for weight-loss medications. “We have members asking why we’re not covering them, but we’re not seeing groups say we should cover them,” See said. “Our answer would be yes, we certainly can, but it comes at an increased cost for all members, not just those who are on the weight-loss medications.”

See said ultimately, the goal for Arkansas Blue Cross is to find successful, sustainable weight-loss solutions for members—solutions that are affordable, tolerable and safe for their long-term health. “We’re certainly hoping to help reduce obesity in Arkansas and across the nation. For members, groups and for payers, it’s in everyone’s best interest to help people get healthier.”