Evernorth, the health services division of Cigna, is debuting a pharmacy benefit management program geared to make Wegovy and Zepbound more available to patients by capping the amount they spend monthly on GLP-1 medications.
Through negotiations with the medications' manufacturers, Evernorth said it will cap patient's monthly cost at no more than $200.
The goal, said Evernorth, is to fill a market need by offering savings and predictability.
"We are reimagining pharmacy benefits to reduce costs and better serve patients," said Adam Kautzner, president of Evernorth Care Management and Express Scripts.
WHAT'S THE IMPACT
The $200 limit will count toward patients' annual deductibles, Evernorth said.
The company estimated that patients could save as much as $3,600 per year when compared with the price they would pay buying from consumer programs or directly through the manufacturer.
Evernorth also intends to simplify and automate prior authorization processes to enable faster access. Patients can select from a broad network of local retail pharmacies or home delivery through Evernorth's EnGuide Pharmacy, staffed by clinicians with specialized knowledge in GLP-1s for enhanced support, the company said.
Meanwhile, health plan sponsors are expected to see a significant reduction in the net cost per prescription of GLP-1 medications.
THE LARGER TREND
Weight loss drugs such as Wegovy and Zepbound are clinically effective but not cost effective at their current prices, according to a March study published in JAMA Health Forum.
Tirzepatide and semaglutide, the generic names for the medications, generate improvements in quality-adjusted life expectancy when they're paired with lifestyle modification, according to the study. But neither medication was cost effective at the $100,000/quality-adjusted life-year (QALY) benchmark due to their high lifetime treatment costs.
The threshold analysis indicates that a substantial price reduction (30.5% for tirzepatide and 81.9% for semaglutide) would be needed to make the medications more cost effective.
Expanding Medicare coverage of anti-obesity medicines could increase annual spending by $3.1 billion to $6.1 billion, according to an August 2024 Health Affairs study.
The authors forecast that if anti-obesity drugs were covered in 2025, and if 5% percent of newly eligible patients were prescribed one, Part D costs would increase by $3.1 billion annually. If the percentage of patients was doubled to 10%, the price tag could rise by $6.1 billion.
Given that more than 70% of U.S. adults had obesity or were overweight as of 2021, the potential market for these products is large, Health Affairs said.
Jeff Lagasse is editor of Healthcare Finance News.
Email: jlagasse@himss.org
Healthcare Finance News is a HIMSS Media publication.