Controlling GLP-1 costs and optimizing health outcomes.

Many Americans struggle with obesity, diabetes, and cardiovascular disease, or a combination of all three, which can be thought of as cardiodiabesity. Collectively, these conditions drive about $719B in annual health care spending.  

Amid this public health crisis, Ozempic has become a household name. It’s a drug that’s part of a group of medications called glucagon-like peptide 1 (GLP-1) agonists. Doctors have used GLP-1s to treat type 2 diabetes for nearly 20 years, and recently the drugs have surged in popularity as a weight loss solution. This skyrocketing on-label and off-label use of GLP-1s for weight loss is straining plan sponsor (the businesses, health plans, unions, government agencies, and public sector organizations that pay for health care) budgets as they seek to balance access and costs. As a company that helps plan sponsors manage their pharmacy benefits and costs, Evernorth pays close attention to the prices that pharmaceutical companies set for popular drugs like GLP-1s. J.P. Morgan Research forecasts that the GLP-1 market is expected to exceed $100B by 2030, driven equally by diabetes and obesity usage, so this issue will only continue to grow.*

As the U.S. health care system grapples with demand for these effective but cost-prohibitive medications, new solutions are needed to expand appropriate, affordable access.

EncircleRx: Cardiodiabesity

To help the plan sponsors that are our clients cover GLP-1s, Evernorth’s EncircleRx program offers the industry’s first financial guarantee. EncircleRx protects plan sponsors from the sharply rising cost curve of GLP-1s through a cost cap or savings (i.e., return on investment) guarantee, which, in turn, helps ensure access for the right patients, improving clinical outcomes and lowering downstream health care costs. This initiative breaks through a critical barrier for plan sponsors seeking to expand access to these effective medications without straining their budgets.

Patients that meet the criteria for a GLP-1 are also enrolled in a proven lifestyle program with behavior change support from a clinical health care team. The program is designed to help patients achieve and maintain improved health. A recent pilot program found that participants who used GLP-1s and were more engaged in this program lost more weight than those who used these medications and were less engaged.   

• Policymakers should ensure the private market maintains the flexibility needed to create targeted solutions, negotiate lower prices, and implement outcomes-based arrangements.

*https://www.jpmorgan.com/insights/global-research/current-events/obesity-drugs