Major payer coverage policies for 11 drugs often met fair access criteria, according to the Institute for Clinical and Economic Review’s (ICER) fourth annual Barriers to Fair Access assessment.1 Where insurers struggled to provide fair access was with several antiobesity drugs, which include semaglutide (Ozempic), liraglutide (Saxenda), phentermine/topiramate (Qsymia), and naltrexone/bupropion (Contrave).
Reviewers found a 70% alignment with ICER criteria for fair access—what the organization calls concordance—for glucagon-like peptide-1 (GLP-1) receptor agonist semaglutide and phentermine/topiramate, an oral medication that helps control hunger. Alignment in cost sharing was rated 81% for semaglutide, phentermine/topiramate, and tirzepatide (Mounjaro), which is approved to treat type 2 diabetes.
Reviewers also found that 30% to 52% of obesity drugs were rejected due to noncoverage. KFF published the results of its annual survey of employer health benefits in October 2024.2 It found that just 18% of companies with 200 or more employees cover GLP-1 agonists, a class of medications used to treat obesity.
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Many plans have policies for offering access to weight-loss drugs, but clients can opt out of that coverage, Sarah K. Emond, MPP, president and CEO of ICER, said in an interview. “We tried to make clear the unprecedented potential budget impact challenge that is represented by these drugs, even though they look like a great deal from a long-term value perspective,” she said. “There are payers that just can’t find a way to offer affordable access.”
For this analysis, ICER reviewed 11 formularies covering 57 million people. These include 10 commercial payers and the formulary from the Veterans Health Administration. The formularies were selected based on information on the largest number of people covered from the Managed Markets Insight & Technology Analytics Market Access Database.
ICER assessed 11 drugs that the organization had reviewed in 2022 for cost-effectiveness. For this analysis, reviewers assessed criteria that ICER has determined are cornerstones of fair access. Alignment for fair access was assessed based on cost sharing to patients and the lowest relevant tier, clinical eligibility not being narrower than the FDA label, step therapy policies that meet standards for clinical appropriateness, and provider qualification restrictions.
The drugs assessed included the following:
- Tirzepatide to treat type 2 diabetes
- Semaglutide, liraglutide, phentermine/topiramate, and bupropion/naltrexone to treat obesity
- Edaravone (Radicava ORS) to treat amyotrophic lateral sclerosis
- Trilaciclib (Cosela) to treat chemotherapy-induced neutropenia
- Fezolinetant (Veozah) to treat vasomotor symptoms of menopause
- Betibeglogene autotemcel (Zynteglo), a one-time gene therapy to treat β-thalassemia
- Valoctocogene roxaparvovec (Roctavian), a one-time gene therapy to treat hemophilia A
- Etranacogene dezaparvovec-drlb (Hemgenix), a one-time gene therapy to treat hemophilia B
New this year was an exploratory analysis of consumer accessibility of the drugs assessed using data from IQVIA’s Market Access Library. ICER looked at prescriptions filled, rejected, abandoned, cash payments, and out-of-pocket costs.
“Partnering with IQVIA gave us the opportunity to see what it feels like for patients from a cost perspective because that’s been missing in previous reports,” Emond said. “We’d always used tiering as a very inadequate substitution for cost sharing, but knowing the range of costs that are coming out of pocket for patients for these drugs was also really instructive.”
Emond said there could be many different cost-sharing amounts for a single tier based on how the purchaser has structured the plan. “It can be a really big difference, and we weren’t able to see that when we were just looking at tiers,” she said. “The IQVIA data [are] not as granular when looking at specific formularies, but [they] gave us a sense of how much patients are paying out of pocket at the pharmacy counter for the drugs. Feedback from our working group over the years was that if we had any opportunity to get to the dollars that patients were paying, that would be a good contribution to the conversation about what represents fair access."
Insurers’ Obesity Drug Coverage
The ICER review found that 3 formularies (Highmark, UnitedHealth, Health Care Service Corp) placed semaglutide and phentermine/topiramate on nonpreferred brand tiers with no other drugs in their class covered at the lowest tier.
Regarding clinical eligibility, one payer (Blue Shield of California) required that a patient has not undergone bariatric surgery within 12 months of receiving phentermine/topiramate, which is not part of the approved labeling or clinical guidelines. The Veterans Health Administration included additional requirements for semaglutide, including documentation of prior use of orlistat not being adequate and specific body mass index and conditions related to type 2 diabetes. ICER said these requirements do not align with clinical eligibility criteria. The Veterans Health Administration also implemented restrictive criteria for the use of liraglutide.
After the ICER review, Blue Shield of California changed a policy to align with the organization’s fair access policies. Effective October 2024, the plan no longer excludes patients who have undergone bariatric surgery within 12 months of receiving phentermine/topiramate.
But Blue Shield of California made another change that makes phentermine/topiramate no longer align with other ICER criteria: Effective September 2024, phentermine/topiramate moved from tier 2 (preferred brand) to tier 3 (nonpreferred brand). This means phentermine/topiramate is no longer on the lowest relevant tier. Because of this change, there is no obesity medication in the same class as semaglutide in the lowest tier.
This article originally appeared on managedhealthcareexecutive.com and has been lightly edited.
To read these stories and more, download the PDF of the Total Pharmacy February issue here.
