By Trish Pearson
Insure Your Future
Trish Pearson
The cost for GLP-1 weight loss drugs will begin to drop beginning July 1. Insurance companies will add Zepbound to their drug formularies by Oct. 1, which will make it easier to prescribe and provide some cost sharing through insurance plans. CVS health will restore coverage of Zepbound and start covering its new obesity pill on its standard drug plans. The new drug, Foundayo, will be added to the formulary beginning July 1. And Medicare recipients will be allowed access to specific GLP-1 weight loss drugs, including Zepbound, at a reduced cost.
What does all this mean?
These medications will be covered by three of the nation’s largest pharmacy benefit managers, including CVS Caremark. Pharmacy benefit managers are third party administrators that manage prescription drug programs for health insurers. They act as the middleman between insurance companies, pharmacies and drug manufacturers.
In other words, they hold all the cards. They negotiate drug prices, create lists of covered medications (formularies), process claims and contract with retail pharmacies. The major PBMs are CVS Caremark, Express Scripts and Optum Rx.
If a drug is not included in an insurance company’s formulary, the patient must pay the entire cost of the medication and it does not count toward the maximum out of pocket threshold.
GLP-1 medications generally cost between $900 and $1,000 per month. By adding them to the standard formulary, the drugs will be assigned a “tier,” which defines the copay. This amount is well below the retail cost; usually less than 25 percent. While it is still expensive, it is much more affordable.
GLP-1 authorizations were also generally only approved for patients who were diabetic or with certain diagnosed heart conditions. It will now be available to treat obesity.
Medicare is expanding its coverage of GLP-1 weight loss drugs. Eligible Medicare beneficiaries will be able to obtain certain GLP-1 medications for $50 per month beginning July 1. The special program will be in effect through Dec. 31.
The program is sponsored by the Centers for Medicare and Medicaid Services, and eligible beneficiaries include those enrolled in a Medicare Advantage plan with prescription drug coverage or a standalone prescription drug plan.
Insurance companies will not send notices to their members, nor will they perform any type of outreach to inform them of the program. Information on the availability and how to participate will come from the prescribing provider during an appointment, or through the pharmacy after CMS approves the provider’s request for authorization.
There is no self-enrollment or sign-up process for beneficiaries. Access to this program begins only when a provider initiates a request.
CMS should share more information when the program starts. The best place to begin is with your primary care provider. They should be informed about the new “bridge program,” which provides increased availability and affordability. As details become available, we will share them in this column.
This is great news for people who are fighting obesity for whom traditional methods alone don’t work. However, it does not replace the need for healthy diets and exercise. It just makes the results much more achievable.
Trish Pearson is a licensed independent insurance agent and certified long term care specialist. Contact her at 203-640-5969 or trishpearson281@gmail.com.