Optum, CVS, Express Scripts GLP-1 programs entice employers

Employers strained by increasing costs and growing demand for blockbuster weight-loss medications are doubling down on partnerships with the biggest pharmacy benefit managers.

CVS Caremark, OptumRx and Express Scripts are pitching CVS Weight Management, Weight Engage and EncircleRx, respectively, which they say help employers provide highly coveted glucagon-like peptide-1 agonists, or GLP-1s, to the right employees in a financially sustainable way.

Related: Mark Cuban Cost Plus Drug Co. clients see promising early returns

Employers are buying into these programs to satisfy worker demand for coverage of GLP-1s such as Wegovy, Zepbound and Saxenda. Others incorporate the PBM offerings into their employee health benefits to constrain access to the $1,000-per-month medicines.

“We're seeing folks turn on coverage with Encircle giving them that predictability, and we're also kind of seeing the inverse,” said Kasey Raetz, vice president of product and pharmaceutical contracting and strategy at Evernorth Health Services, the Cigna subsidiary that includes Express Scripts.

“Encircle is kind of that soft landing spot, so they don't have to turn coverage off completely,” Raetz said. Cigna introduced coverage of these weight-loss medications for its own employees via EncircleRx in July, she said.

About 70% of employers planned to cover GLP-1s for obesity this year even though nearly all indicated they were "concerned" or “very concerned” about appropriate use and long-term costs, according to a survey the Business Group on Health conducted last summer.

“The cost is simply unsustainable, so for those covering now, many of them are rethinking: Can I even continue to do this at the rate that the utilization and costs are going up?” said Chantell Sell Reagan, national pharmacy practice clinical leader at the benefits consulting company WTW.

The PBM pitch

Slashing the number of people taking the medications — whether by ensuring only the highest-need and most committed patients use GLP-1s, "deprescribing" after patients achieve goals or cracking down on improper use — is driving the biggest near-term cost savings for employers tapping into the programs.

“The drug is definitely an important part for some, but the lifestyle and behavior change needs are important for everyone,” said Josh Fredell, senior vice president of PBM, payer and life science solutions at CVS Caremark, a subsidiary of CVS Health.

About 150 clients have adopted CVS Weight Management since it rolled out in 2023, and most are implementing it in conjunction with GLP-1 coverage. The company declined to specify the number of people enrolled in the program but said about 3.5 million are eligible.

All three PBM offerings couple GLP-1s with lifestyle requirements, such as meeting with registered dietitians, talking with health coaches and tracking weight.

“Those are the patients that our clients are really interested in providing that weight-loss benefit. They're not necessarily interested in providing couple-of-month coverage for somebody that maybe isn't serious about that journey,” Raetz said.

Starting last May, participants in Express Scripts' EncircleRx gained the option to use its diabetes program, weight-loss program or both. Weight-management clients can choose to either save at least three times what they pay to participate or to cap their spending on GLP-1s at 15% of their previous year’s trend.

About 9 million people among 400 clients are using the EncircleRx diabetes and weight-loss programs, which saved health plans more than $50 million in the first seven months of last year, Raetz said. Some of the savings came from Express Scripts investigations into fraudulent use of GLP-1s by prescribers and members, she said.

Similarly, OptumRx launched Weight Engage at the start of last year. The initiative lets plan sponsors decide what guardrails to put in place, such as limiting GLP-1s to members with a certain body mass index or cardiovascular risk factors, and select a nutrition, lifestyle or medication-focused program, said Tricia Purdy, senior vice president of strategy and product at OptumRx, a unit of UnitedHealth Group subsidiary Optum.

Weight Engage participants are given One Pass Select fitness memberships that grant them access to thousands of gyms at no additional cost. OptumRx said more than 20 clients use Weight Engage but declined to specify the number of people participating.

“What we have taken is a really comprehensive approach in structuring a healthy weight-loss benefit, including coverage flexibility, utilization management options and member support programs,” Purdy said.

Weighing other options

Still, broader scrutiny of the biggest PBMs is driving some employers to weight-loss offerings managed by smaller PBMs such as Liviniti and TrueRx Health Strategists or vendors such as Personify Health and Good Measures.

Express Scripts recognizes the obesity epidemic is too big an issue to tackle on its own. The PBM partners with digital health company Omada Health for its obesity program. “We know that a lot of these vendors truly do have best-in-class platforms,” Raetz said.

Seth Friedman, pharmacy and health plan services leader at the insurance brokerage Gallagher, is hesitant to advise his clients to sign up for weight-management services offered by the biggest PBMs, especially given accusations these companies withhold pricing information, pocket drug rebates and influence higher drug prices.

“You're better off working with a different party that doesn't necessarily own the dispensing end of it, if you will, or it doesn't necessarily benefit from a rebate," Friedman said.

However, employers partnering with weight-loss vendors may be dealt additional fees associated with sharing files and other data between PBMs and vendors, Reagan said.

Robust GLP-1 demand

The use of GLP-1s for weight loss is expected to rise 73.1% this year, driven by growing patient interest and greater willingness from providers to prescribe them, according to a report the Evernorth Research Institute published Tuesday. The Cigna unit based its findings on pharmacy claims, scientific research, and surveys of employees, employers, providers and health insurance executives.

“As we embrace their promise, we must also confront one of the greatest healthcare conundrums of our time: How to ensure these treatments remain accessible to those who need them most while preventing financial strain on healthcare systems, employers and individuals,” the Evernorth report concludes.

With GLP-1 demand and use cases for the medicines not expected to slow, the biggest PBMs are considering additional health and cost-saving opportunities in this space.

The jury is still out on the long-term savings from reducing obesity-related diseases, Raetz said, but the Evernorth Research Institute is pursuing additional research to track the effects on cost of care. Cigna is also considering how to improve reimbursement for some pharmacies dispensing these medications, she said.

In addition, CVS Health is thinking about how to support people who struggle to maintain muscle while taking GLP-1s, and is monitoring research on deprescribing, Fredell said.

“There's no disputing the drugs are effective. There's no disputing there's demand for the drugs. I think the biggest challenge is continuing to manage these drugs while being faced with the increased use and the increased cost,” Reagan said.