The Impacts of GLP-1 Utilization Management Criteria

By A. Azim Bari, PharmD, MBA, BCPS , Chief Clinical Officer for Gateway Health Partners

In the nearly two decades since their introduction to the market, there has been a steady increase in the number of glucagon-like peptide-1 (GLP-1) agonist class products. Most recently, a newer generation of GLP-1s that includes semaglutide (Ozempic, Rybelsus and Wegovy) and trizeptide (Monjouro and Zepbound) have shown to be significantly more effective than older GLP-1 products for both the treatment of type 2 diabetes and chronic weight management.

The improved outcomes of these GLP-1s led the American Diabetes Association to move Ozempic and Monjouro to first-line therapies for specific type 2 diabetic patients, eventually leading to the FDA approval of Wegovy and Zepbound for chronic weight management. However, many patients who find they are unable to get Wegovy and Zepbound covered for chronic weight loss have resorted to off-label use of Ozempic and Monjouro, creating supply chain constraints and drug shortages that are negatively impacting type-2 diabetes patients who need these drugs to help treat and manage their disease.

As plan sponsors focus on providing population-based care, they've carefully reviewed the clinical data around GLP-1s to develop utilization management criteria for managing diabetic patients in a way that's both clinically appropriate and cost-effective. However, a review of the GLP-1 utilization management criteria currently allowed by manufacturers limits rebate options for plan sponsors pursuing lower net costs to ensure clinically appropriate GLP-1 usage, creating challenges in navigating their coverage options.

These impacts make it even more critical for plan sponsors to understand the implications of the current manufacturer utilization management criteria and their options regarding coverage criteria and rebate qualifications. Initial study results of GLP-1s are promising. However, the long-term impact on the total cost of care has yet to be seen and will be something Gateway Health Partners continues to help our clients navigate as new GLP-1 drugs enter the market in the coming years.

How Gateway Health Partners Can Help

With predictability and transparency at the forefront of everything we do, the team at Gateway Health Partners is committed to providing you with the necessary support and guidance to help you understand the impacts of GLP-1 utilization management criteria allowed by manufacturers so you can confidently navigate your options for cost-effective population-based care.

?Whether you are interested in optimizing rebates or pursuing lower net cost with stricter utilization management criteria requirements, our experts understand there is no one-size-fits-all solution for GLP-1s. We are here to help you navigate your options to maximize your savings, and will continue to provide ongoing support with updates on market changes, clinical insights and new GLP-1s seeking FDA approval before they enter the market, ensuring you are always up to date and well-informed. ?

?Interested in learning more? Email Scott Webb at [email protected]

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