Q&A: How GLP-1 Complexities Highlight Challenges in Pharmacy Benefits

Amid the rise in popularity and constant discussions surrounding glucagon-like peptide-1 (GLP-1) medications, many stakeholders in the pharmacy industry have attempted to navigate significant complexities within this drug class. Whether it’s the patients taking them, the pharmacists dispensing them, or the pharmacy benefit managers (PBMs) determining coverage, the challenges and hurdles of GLP-1 benefits highlight a larger issue within the pharmacy industry.

“I don't know the last time that we've seen a drug in market that provides this level of clinical value, where there's not just one drug in market, there's a few,” Rae McMahan, senior vice president of payor solutions at Prescryptive Health, told Drug Topics. “There are more drugs that are coming and the dynamic of what you have to pay is drastically different across different plans. It is very complex, and I feel like this sheds light on the challenges that we have within the pharmacy ecosystem.”

In part 3 of our interview series with McMahan, she tapped into her experience with Prescryptive to discuss how patients and providers are encountering GLP-1 medications. With such a life-changing drug class rising to the general public’s subconscious, she believes more needs to be done for patients to truly see their pharmacy benefits as cost-effective approaches to accessing and using GLP-1s.

READ MORE: Q&A: The Pharmacist’s Burden Associated With Dispensing GLP-1s

Drug Topics: Where do pharmacy benefit managers fall in place regarding GLP-1 access and cost?

Rae McMahan: It's another one where there's a full gamut. There's PBMs that have it covered. A lot of times, the employer [makes] the decision to include that and then also [determines] the right clinical criteria that they're managing too. Are they managing to label and then going through that process? Then, some PBMs have preferred products out there. But I would say, when they do cover the products, oftentimes you have to meet clinical criteria. Oftentimes these employers also have a weight health or an obesity management program that you have to enroll in at the same time. You have this dynamic of drug covered under pharmacy benefit, potential program covered under medical benefit, and then these different copay levers between the 2, which then also makes it a little bit challenging.

Where I've seen success is where these medications are covered under a limited benefit offering, or even like a lifestyle management benefit offering, where the employer requires the members to meet clinical criteria. They're able to give some members some flexibility in the coverage of these medications, and it's a lot more coordinated and focused, rather than it going through the general PBM flow and population. [Flexibility is important] because of all the different levers and because of the cost and really wanting to support members that need this medication, versus those that would prefer to have it [but are] not necessarily meeting those clinical criteria. [It’s] a large gamut, but I found the most success when there's a program that really limits the coverage, not from an accessibility perspective, but can be more concierge-level to help members through all of the hurdles they have to get through to get this medication.

Drug Topics: With the rising popularity of GLP-1s, it seems that all stakeholders involved have to deal with the growing complexities that this drug class presents. Would you agree with that sentiment?

Rae McMahan: I do agree, and I hope we can get to a better level to relieve some of those challenges. I don't know the last time that we've seen a drug in market that provides this level of clinical value, where there's not just one drug in market, there's a few drugs in market. There are more drugs that are coming and the dynamic of what you have to pay is drastically different across different plans. It is very complex, and I feel like this sheds light on the challenges that we have within the pharmacy ecosystem. My role at Prescryptive is to help employers understand how they can truly have a pharmacy benefit that is a benefit. [We’re] leveraging our transparent and pass-through component but also our technology that empowers the member at point of prescription.

We want to avoid the challenges at the pharmacy counter, whether it's virtual or in-person, and we want that member to have the information they need so they know how much it costs, where they can get it, [and if] they have to have a prior authorization. [We want to] relieve that headache at that point in time. Similar to the shopping experience that we now appreciate for other consumer goods, this is a perfect storm for us to apply that same logic and utilize the technology that we have to help that member, that pharmacist, that physician, that employer, ensure that they are truly providing benefits to their pharmacy coverage.

Drug Topics: How is Prescryptive helping pharmacies and patients navigate these industry-disrupting trends of GLP-1 cost and access?

Rae McMahan: It's 2-fold. One, we talk about the affordability of the medication and what type of benefit offering, whether it falls under PBM, or a limited benefit offering, and we talk about what we see as the appropriate copay to provide adherence to these medications. That is one component, just the overall benefit offering for the employer. The second component of that is the technology, where the prescription gets sent to the member's phone. It's not an app; it gets sent to their phone so that they can see their prescription and they can understand their insurance coverage, as well as any cash coverage at the same time. The biggest component of that is it's not retrospective or after they're getting the medication, but it is [before they get] to the pharmacy.

That is a very important driver of empowering that member to have individualized information at their fingertips to avoid the chaos. Them just saying, ‘I can't afford it, I don't know where to get it, it's too much, and I'm not going to take it’—that's really unfortunate for the outcomes that these medications provide. We feel that's really an important driver of utilization of these medications. Couple that with the right benefit design and the right technology to support it, and of course the clinical parameters in between, all of that needs to be really coordinated.

READ MORE: Q&A: How Increased Popularity, Minimal Access to GLP-1s Create Patient Barriers

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