LAS VEGAS — The onus should be on providers — not insurers — to determine which patients may access glucagon-like peptide agonists, or GLP-1s, Highmark Chief Medical Officer Dr. Timothy Law said at the AHIP 2024 conference.
During a keynote session at the health insurance industry gathering on Wednesday, Law and other executives discussed Highmark’s approach to covering costly blockbuster medications such as Ozempic and Mounjaro, short supplies and how bariatric surgery fits into the picture.
Related: Insurers, PBMs restrict access to weight loss drugs as demand soars
The unprecedented demand for these expensive and hard to source drugs for diabetes and weight loss have left health insurance companies grappling with rising costs. Highmark reported higher-than-expected utilization of the $1,000-a-month medications during the first quarter, to the detriment of its profits.
Clinicians, Law said, are prescribing these medicines to too many patients, compelling health insurance companies to clamp down.
“I fear it's going to get pushed back to the insurance companies to be the bad guys,” Law said during his remarks.
In an interview, Law expanded on his comments. “If the doctors are going to fold up and say, ‘We don't want to decide,’ and make us decide, then they can't come back on the back side and say, ‘I'm sorry, I can't give you the script because your insurance company doesn’t allow you to have it,’” he said.
GLP-1 drugs are a major area of interest at AHIP 2024, which began Tuesday and ends Thursday.
“It's the hottest topic I have dealt with, with each and every client that I speak to, regardless of whether they're a health plan or a labor union or employer,” said Adam Kautzner, president of Cigna division Express Scripts. “What are we going to do about the GLP-1 products? Social media has taken this one by storm.”
One in eight U.S. adults has taken a GLP-1 and that 6% are currently using the one of the drugs, KFF reported last month. Most patients have taken them for chronic conditions such as diabetes or cardiovascular disease, while 38% sought to lose weight, the survey found. About 142 million Americans — more than half of the adult population — meet the Food and Drug Administration’s prescription criteria, according to the Institute for Clinical and Economic Review.
Insurers have imposed restrictions to limit access. For example, GLP-1s may only be approved for patients with multiple comorbidities, those who participate in diet and exercise programs, or those who try lower-cost alternatives first. Some insurers also are setting higher body mass index cutoffs than the FDA's.
Highmark follows FDA standards and doesn't require lifestyle modifications for patients to qualify for GLP-1s, Law said. “I just don't think we should get into the medical side of things and get between the doctor and the patient,” Law said. “We should be conduits to care, not roadblocks.”
Presenters at the AHIP event emphasized that bariatric surgery remains an alternative for patients who need to lose weight.
Moreover, said Dr. Melanie Jay, professor at the New York University Grossman School of Medicine, these procedures are well-understood, may be performed on a less costly outpatient basis, can be more effective and don't require patients to maintain use of a medication over time.
Providence Health Plan will expand GLP-1 coverage for weight loss and management under its employer plans next year, Commercial Market President Scott Burton said Wednesday. The same day, Blue Cross Blue Shield of Michigan said it will end GLP-1 coverage for fully insured large group plans in January.
“This is not a class of drugs that's going to go away anytime soon. In fact, it'll probably start to be approved for more and more uses, and so we're going to need to evolve,” Burton said. Providence Health Plan is a subsidiary of Renton, Washington-based Providence Health and Services.