GLP-1 medications can deliver significant weight loss results, but high price tags can make them difficult for many to access or stay on — often because of inconsistent or nonexistent insurance coverage.
These changes should effectively increase the number of Americans who can access these medications through their existing health insurance.
“This is a significant development for obesity treatment access,” says Christine Bonarrigo, PharmD, a clinical pharmacist at Tufts Medical Center in Boston. “It also signals that obesity care is continuing to move into the healthcare mainstream, rather than being treated as optional or cosmetic.”
What Is a Pharmacy Benefit Manager, Anyway?
“Pharmacy benefits managers are a ‘middleman’ between the insurance companies, pharmacies, and manufacturers,” explains Jamie Alan, PharmD, PhD, an associate professor of pharmacology and toxicology at Michigan State University in East Lansing.
“They help to decide what your copay is for medications, and whether or not these medications are covered,” she says. Pharmacy benefit managers create a list of covered medications, and this list is called a formulary, she adds.
The nation’s largest pharmacy benefit managers — CVS Caremark, Express Scripts, and Optum Rx — will now include Zepbound and Foundayo in their formularies, per Lilly.
Collectively, these PBMs manage nearly 80 percent of prescription drug claims in the United States, covering about 270 million people.
CVS Caremark removed Zepbound from its list of covered drugs last year, prompting backlash from patients and a class action lawsuit. Express Scripts and Optum Rx have continued to cover Zepbound.
CVS Caremark will begin covering the Foundayo pill on June 1. Zepbound will be added to its formulary starting October 1. For some patients, that means these medications could be available for as low as $25 a month.
Lilly also announced that, starting July 1, some Medicare Part D beneficiaries will be eligible to pay $50 per month for these medicines.
Will This Make Zepbound or Foundayo Easier for You to Afford?
While the addition of medications to the pharmacy benefit manager formulary can make coverage more widely available, it doesn’t guarantee these drugs will be covered.
“‘Covered’ does not automatically mean ‘easy to access,’” Dr. Bonarrigo says. “Many patients will still face prior authorization requirements, BMI criteria, employer-specific exclusions, step therapy rules, or high out-of-pocket costs, depending on their individual plan. Coverage policies can also vary widely between employers.”
To know if Zepbound or Foundayo will be covered by your insurance, Dr. Alan recommends contacting your health insurance provider directly to ask. (You can also do an insurance check for Foundayo and Zepbound online.)
But doctors agree that this is a step in the right direction. “Anything that can expand the coverage for these medications is going to be helpful,” says Mir Ali, MD, the medical director of MemorialCare Surgical Weight Loss Center at Orange Coast Medical Center in Fountain Valley, California. “These medications are quite expensive if they’re not covered by insurance, and a lot of people can’t afford that.”
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