Pharmacists Can Help Patients Navigate GLP-1 Access, Affordability, and Long-Term Use

Pharmacy Times interviewed Deanna Horner, PharmD, BCPS, executive vice president of Eversona Enterprise Direct Strategy, on sustainable GLP-1 coverage models, payer and employer considerations, patient support needs, and the role pharmacists can play as access and affordability pathways continue to evolve.

Pharmacy Times: As demand for GLP-1 therapies continues to grow, what would a sustainable coverage model look like—one that expands access for appropriate patients without creating unmanageable costs for employers, health plans, or the broader health care system?

Deanna Horner, PharmD, BCPS: We picked a great day to meet, considering July 1 marks a major milestone for GLP-1 coverage. It is the kickoff of the CMS Medicare GLP-1 bridge program, which is an 18-month demonstration project that aims to study how access can be expanded through clear clinical eligibility criteria, predictable patient cost sharing, and centralized administration.

In the demonstration, patient cost sharing is set at $50 per month, and the program is outside of traditional plan risk. The objective is to identify a more consistent and scalable path for a large population, such as the Medicare population, that does not currently have access to GLP-1 therapies through Medicare Part D when they are used for weight management. Of course, Medicare does cover GLP-1 therapies for other indications that are not related to weight loss.

The lessons learned from that short-term demonstration will be used to inform future payer coverage rules. There are also some parallels with how we think about direct models at Eversona, where we offer streamlined onboarding, transparent pricing, and integrated patient support for both patients and employers. We are focused on offering that in a frictionless way beyond traditional coverage rules.

Ultimately, I think the future state for GLP-1 access is likely going to be a hybrid approach, where lessons learned from a CMS-style framework are applied alongside learnings from direct strategies.

Pharmacy Times: Coverage discussions often focus on the acquisition cost of GLP-1 medications. What clinical outcomes, medical cost offsets, and long-term measures should payers and employers consider when determining the true value of these therapies?

Horner: Since you mentioned both coverage and the clinical pieces, I will start by saying that at the beginning of my career, I was a clinical pharmacist on the health care provider side. In the United States, there is a disconnect between how clinical reasoning plays out and how access aligns in practice.

Typically, a patient’s indication for use and goals of therapy are determined through the patient-provider interaction. For example, a patient using a GLP-1 therapy for weight management may have different goals of therapy than someone using a GLP-1 therapy for obstructive sleep apnea.

However, because of the way patients typically pay for their medications, it becomes more challenging to consider those patient-specific scenarios when creating benefit design, utilization management rules, and policy at the population level. More than 85% of people in the United States use insurance to access therapy, so coverage decisions are often made across populations rather than around individual patient circumstances.

Payers, including pharmacy benefit managers, health plans, and employers, start the coverage decision-making process by looking at the clinical and safety components of specific medications. However, they also have to determine, from a practical standpoint, how they are going to pay for those medications for the population they serve.

In addition, costs may or may not be viewed holistically across pharmacy benefit and medical data. Ideally, both sides would be considered. When we think about cardiometabolic medications and cardiovascular risk reduction, for example, the clinical benefit may not be seen for 10 years. The goal is often to reduce the risk of an event over a long period of time.

From a payer standpoint, there are trade-offs. They are thinking about how they can pay for therapy today while also accounting for clinical benefits that may occur years later. Health plans may have an easier time evaluating that because they may not have as much turnover in their populations.

At the employer level, they are also considering what they can afford within their budget and how long employees may stay with them. If they invest in coverage today, will those patients still be with the employer 5 or 10 years from now when the clinical benefit is realized?

There may also be earlier indicators of value for employers. For example, if an employer is covering GLP-1 therapy for obstructive sleep apnea, employees with that condition may experience improved daytime alertness, less absenteeism, and less presenteeism. There is a lot to consider, and it is important to evaluate value from the clinical side, the payer side, and the specific population being served.

Pharmacy Times: How can benefit designs incorporate meaningful clinical safeguards without creating prior authorization requirements or administrative barriers that delay treatment for patients who are likely to benefit?

Horner: Two major areas we see used on both the payer side and among vendors are data and automation. Everyone should be thinking about how to use data to understand what is already known about the patient so they can determine appropriate use without requiring patients to go through traditional hurdles, such as prior authorization.

That is one key piece: using the data available to create smarter options for patients rather than relying on manual processes that are becoming outdated.

The second piece involves the vendors we work with that offer behavioral health programs or weight management programs on the front end. That connects back to the patient-provider interaction I mentioned earlier. Providers in those programs are making decisions based on the patient they are meeting with, and that has been an effective way to identify which patients may be best suited for a specific treatment and get them into the process earlier.

Pharmacy Times: GLP-1 treatment requires more than simply providing access to a medication. What services—such as pharmacist counseling, nutrition support, adherence monitoring, dose management, or adverse effect management—should be incorporated into comprehensive care models?

Horner: Even the label indicates this, but these medications work best when they are layered with appropriate nutrition support, behavioral interventions, and similar services. Pharmacists can serve a huge role here, especially because adherence and persistence to therapy have been quite poor. It has been noted that less than 30% to 50% of people continue use beyond 3 months, 6 months, or 12 months. That is a huge opportunity for pharmacists to step in.

It is also about bringing it back to basics. When I was in pharmacy school, we talked about 3 basic questions that you would start a consultation with. For people who are thinking about therapy, are about to start therapy, or have already been on therapy, pharmacists should be checking in because of the poor adherence and persistence problem.

The first question is: What is the medication for? Pharmacists should make sure the patient understands the medication, understands their care plan, and can connect that back to the discussion they had with their health care provider. What did the provider tell them? What gaps need to be filled?

The second question is: How do I take it? There has been a lot of misunderstanding among patients. On our end, we have worked on patient surveys and interviews to better understand adherence and persistence. A lot of people do not realize that these are chronic medications. These are therapies they may be on for an extended period of time. Pharmacists can help set those expectations up front.

The third question is: What should I expect from this medication? The adverse effect profile is key. These medications are generally well tolerated; however, many patients experience nausea and vomiting, especially as they slowly increase to a target dose. Pharmacists can help set the stage so patients understand what to expect, know what the next best action is if they experience adverse effects, and understand nonpharmacologic ways to help them through periods of nausea. Those are the kinds of interventions that can set patients up for success, and pharmacists will be key there.

Pharmacy Times: What role can pharmacists play in identifying appropriate candidates, managing expectations, supporting persistence, addressing adverse effects, and helping patients navigate increasingly complex GLP-1 coverage and affordability pathways?

Horner: This is a pharmacist’s bread and butter. Pharmacists go to school to do all of the things you just mentioned.

A pharmacist can be a patient’s best advocate. Pharmacists are accessible to patients, so it is important for them to stay up to date with the literature and understand what is available from different companies and programs that can help patients access and afford therapy.

That should be part of the pharmacist’s role as a lifelong learner. Staying current allows pharmacists to be advocates for patients and help them navigate these increasingly complex access and affordability pathways.

Pharmacy Times: As direct-to-employer, direct-to-patient, and manufacturer-supported access models become more prominent, what opportunities do these approaches offer, and what safeguards are needed to preserve continuity of care, transparency, clinical oversight, and equitable access?

Horner: That is a great question. I spend a lot of time thinking about these types of direct offerings, designing them, and working with both payers and manufacturers on them.

At the most basic level, whether it is direct-to-employer, direct-to-patient, or a manufacturer-supported program, direct models are designed to simplify the patient journey. The goal is to ensure that patients who have symptoms in the community can be identified and brought into the health care ecosystem. From there, they can access a health care provider who can help them understand their therapy options, get them on a therapy, make sure they can afford and access it, and then help them stay successfully on therapy.

I believe these models will become more prominent over time. As technology becomes more sophisticated, we will move toward a more patient-centric approach that meets patients where they are and where they want to be served, while also preserving continuity of care with the health care provider and the pharmacy.

The challenge for the industry now is making sure we are designing things for the future. These models need to be future-proof and future-forward. We need to think through the safeguards, fail fast if something is not working, take those lessons, and apply them to the next evolution and design.