Five Things to Know about GLP-1’s and Utilization Management

By Azim Bari, Chief Clinical Officer for Gateway Health Partners

With predictability and clarity at the forefront of everything we do, Gateway Health Partners is committed to sharing our insights and expertise to help you stay informed and navigate your options as GLP-1s continue to transform the healthcare landscape.

The Rising Popularity of GLP-1s

It’s been nearly two decades since GLP-1s were introduced to the market and they are still going strong. Most recently, a newer generation of GLP-1s that includes semaglutide (Ozempic, Rybelsus and Wegovy) and trizeptide (Monjouro and Zepbound)
has been shown to be significantly more effective than older GLP-1s for managing type 2 diabetes and chronic obesity.

The improved outcomes of these GLP-1s led the American Diabetes Association to move Ozempic and Monjouro to first-line therapies for specific type 2 diabetic patients and shortly after led to the FDA approval of Wegovy and Zepbound for chronic weight management.

GLP-1 101: The Product and The Problem

A GLP-1 (a glucagon-like peptide-1) agonist, like Ozempic, for example, mimics a natural substance in the body that plays a crucial role in helping our bodies maintain blood sugar balance by stimulating the release of insulin and suppressing the excess
release of glucagon, which also helps control appetite and contributes to feelings of fullness after eating.

As studies continue to show that these types of GLP-1s are effective for weight loss and other potential health issues, the demand for these drugs has increased exponentially. Many patients, unable to get Wegovy and Zepbound coverage for weight loss, have resorted to off-label use of Ozempic and Monjouro, GLP-1s that are intended for type-2 diabetic patients, creating drug shortages, supply chain constraints and the desire by many health plans to try and reduce off-label usage.

The Demand for GLP-1s is Only Projected to Grow

Despite current supply chain constraints and drug shortages, utilization of GLP-1 products is still well below the potential population that may benefit from this type of therapy.

Some analysis suggests that GLP-1 usage for the treatment of diabetes will increase from 10-12% of all diabetic patients today to 35% of all diabetic patients by 2030. It also indicates that by 2030, a projected 30 million people (an estimated 9% of the entire
population) will utilize GLP-1s to treat chronic weight management and type 2 diabetes, pushing the market for these drugs to an estimated $150 billion by the early 2030s.

There’s More in the Pipeline

The utilization and cost projections above may be conservative estimates due to the extensive pipeline of new GLP-1s under investigation and in clinical trials for the treatment of diabetes, chronic weight management and other conditions, including but
not limited to metabolic dysfunction-associated steatohepatitis (NASH/MASH), sleep apnea, polycystic ovarian syndrome (PCOS), Alzheimer’s, chronic kidney disease, heart failure and addiction.

Knowing that more GLP-1 agonists are on the horizon, it is even more important to understand the impacts of clinically appropriate utilization management and rebate optimization for this class of drugs as soon as possible.

The Impacts of Clinically Appropriate Utilization

Due to the continued popularity of GLP-1s, off-label usage, and drug shortages many plan sponsors are navigating strategies for providing cost-effective population-based care for their diabetic patients. However, current utilization management criteria allowed by manufacturers limit rebate options for plan sponsors pursuing lower net costs to ensure clinically appropriate GLP-1 usage, creating challenges in navigating their coverage options.

How Gateway Health Partners Can Help

Gateway Health Partners is committed to helping you understand GLP-1s, the impacts of manufacturer’s utilization management criteria requirements and your options for providing cost-effective population-based care.

Whether you are interested in optimizing rebates or pursuing lower net cost with stricter utilization management criteria, our experts understand there is not a one-size-fits-all solution for GLP-1s. We are here to help you navigate your options to maximize your savings and will continue to provide ongoing support with updates on market changes, clinical insights and new GLP-1s seeking FDA approval before they enter the market, ensuring you are always up to date and well-informed.

Email Scott Webb at [email protected] to learn more.