Access to medication is imperative

With cost reductions and the TrumpRx initiative that has reduced direct-to-consumer prices have created new access for GLP-1s like we’ve never seen it before. With these changes plan sponsors can balance providing access to these life-changing treatments while still managing costs through alternative pay models like RxSaveCard.

Integrated care is necessary when providing GLP-1 access

the need for flexible, sustainable obesity management strategies that prioritize a clinical approach and wraparound care are the best driver for effective treatment, medication adherence, metabolic control, and fiscal responsibility.

Your employees are thinking about GLP-1s as a benefit

Employee demand for obesity medications has reached fever pitch levels, with some people even willing to change jobs for key coverage. With the prevalence of obesity being what it is, it’s not unrealistic to assume a growing expectation around demand for obesity medications.

Jason Macaleer

All right. Welcome to the Expanding Access to Obesity Care webinar. I am Jason Macaleer. I’m going to play host here over the next sixty minutes in an attempt to facilitate what we hope is going be an engaging conversation around the evolving state of obesity care.

Ultimately, the goal here is to share a few insights, maybe some innovative approaches to accessing high quality, clinically appropriate, of course, obesity care. I’m joined here by two guests, two titans of industry. We’re going do a quick intro here in a minute, and then we’ll get to some of the content. We are just sort of some housekeeping items.

We’re gonna try to allow for a few minutes of q and a at the end, but you can also feel free to submit any questions or comments, thoughts, feedback via the chat feature here, and we’ll do our best to address them as we go, either in the chat, or we’ll just take a moment to talk through them live. So again, my name is Jason Mackleer. I currently serve as the chief strategy officer for Vida Health, a virtual obesity and cardiometabolic care clinic. I’ve been in health care for about the past twenty years.

I’ve worked with health plans, health systems, a lot of self funded employers. For about the past twelve years, I’ve worked in digital health, having spent most of that time in cardiometabolic care and care navigation. So excited to have the conversation today, excited to facilitate. Julia, can I ask that you introduce yourself next?

Julia Croxen

Thanks, Jason. Excited to be here and excited to be with all of you as well.

My name is Julia Croxson. I’m the VP of strategy consulting at Rock Health Advisory, which is a boutique strategy group working with enterprise organizations, payers, employers, pharmaceutical companies, etcetera, in their digital health and health care innovation strategy. I spent the past two and a half years doing a lot of work for all different stakeholders as it relates to obesity.

And for the last two years, also really deep in the direct to patient strategy work, in support of some of our pharma clients. So really excited to to bring that perspective to the conversation.

Chris Crawford

Hi, everybody. Chris Crawford, founder and CEO of Rx SaveCard. So we founded the business in August of two thousand and twenty four to meet the need of this cash marketplace, which we’re really looking excited to talk about today. Prior to that, in pharmacy benefit consulting and also in pharmacy benefit management with a vendor. And then prior to that, general health and welfare consulting. So it’s a long winded way of saying I’m old, and I’ve been doing this for a while. And we’re really excited about this conversation because for all the time we’ve been doing it, the change that we’re seeing and the pace and the acceleration, I’ve never seen anything like it, and we’re really looking forward to this conversation.

Jason Macaleer

Perfect. Thanks, Chris. So I’m going to I’m going to do my best to kind of tee up each slide and then and then pepper Chris and Julia with questions and hopefully facilitate engaging dialogue. So a bit of an agenda slide here, but we’re going to be packing unpacking all of this in a lot more detail. But just a few things here that sort of jump out. It should come as no surprise to see that obesity care and and the accompanying medications has reached this frenzy like status here in the US.

Cell phone employers seem to be bearing the brunt of that frenzy. I can’t I can’t recall a time when consumer demand has for a medication like Wegovy or Zepbound has reached such a fever pitch.

I saw an article recently that cited three in four employees will consider GLP coverage when deciding to take a job or to stay at a job, and three in ten employees would actually leave their current job to seek GLP coverage. So clearly a a growing expectation around coverage and and demand for obesity medications.

With the prevalence of obesity being what it is, it’s not unrealistic to assume, you know, you could have upwards of forty percent of plan members prescribed an anti obesity medication, again, potentially in perpetuity, at a price that right now costs about ten thousand dollars per member per year.

Gross of rebates, I should be clear on that. And then there’s more GLP one anti obesity type medications currently in the pipeline expected to hit the market this year, which will likely keep demand and prices for medications elevated.

And there’s new conditions as well for which GLP ones will be approved. We’ll talk through some of that here in the coming slides. But so you could have even larger portions of plan members being prescribed to GLP one. So while it feels like there’s been an explosion in demand and costs associated with obesity management space, there clearly has been, I think we’ve yet to kind of reach the peak. I think that tidal wave is still sort of cresting, so to speak. And and many more folks could be on a GLP one or be asking to to be on a GLP one here in the coming cycles. So a lot of change, a lot of evolution happening.

And the fuel to the fire for plan sponsors, and we’re gonna spend some time talking about this today, is around the increasing complexity for plan design and formulary changes. We saw CVS remove Zepbound from its preferred formulary, replace it with Ogovi. Obviously brought a lot of friction for members who had to switch. It brought a lot of headaches for plant sponsors who had to deal with frustrated members and medical necessity exceptions.

But to Chris’s point here at the opening, we also have seen an emergence of this cash pay model from the pharmaceutical manufacturers, and that’s created a lot of interest in potential off formulary models and designs that, you know, explore some creative ways to take advantage of these, you know, often lower cost or at least more transparent cash pay prices.

So a lot happening, a lot changing, short order. I think it requires plan sponsors to have a thoughtful obesity management strategy, a strategy that can kind of flex and evolve as the space does. And we’ll hear more about that here in the coming slides. But but first first, kind of question for both Chris and Julia.

Chris, I may start with you. You know, this is a webinar about obesity care. And so before we get into the nitty gritty, we’d love to maybe hear your thoughts on why a plan sponsor, a self-funded employer, should care about obesity management. There’s an argument that could be made that, you know, covering obesity care or obesity care medications is a, you know, poor investment.

Doesn’t yield long-term outcomes or or cost savings to the plan. So we’d just love to get your thoughts about that, Chris, and maybe Julia, then yours.

Chris Crawford

Yeah. So the employers we’re talking to, I think they go in a couple of different camps. Right? So one, believe in the long term effect of this is gonna make our members healthier.

This is gonna result in kind of a more engaged workforce. This is also selfishly gonna reduce our future plan spend if people can kinda meet that goal weight, and so that’s the way they wanna support it. I think we see other employers who are being a little bit more reactive to just employee demand. Jason, I think you mentioned the stat.

Right? It’s like people are checking, do I have coverage for this medication? And I’m gonna pay out of pocket. I mean, if you talk to people who’ve been on these medications, you will hear stories of life changing and they’re inspirational.

Like, people get very passionate about it. So I think employers are stuck in the middle feeling a little bit of the demand from the employees. They’re facing a rising cost. And almost every employer you talk to, when they made the decision to cover the medications, whatever that was, they had one budget in mind and an expectation.

And now that budget has been totally blown out of the water. Like, a common theme, all we hear is our utilization is hockey sticked. It’s kind of what you’ll say. So it’s got these employers in this position, which is we want to cover it. Maybe we believe in it, but we don’t know how to financially support it. And I think that’s the challenge that employers are facing right now.

Jason Macaleer

That’s super interesting. Julia, a portion of this webinar is dedicated to to some of those formulary considerations that we talked about with cash pay prices and the like. Could you help articulate you’ve got great perspective. You’ve written articles and thought leadership pieces on some of the strategies that you’ve seen from the pharmaceutical manufacturers as they start to offer these cash pay prices on medications and they look to establish, you know, more direct relationships with patients. Can you maybe talk a little bit about that and and and why that model may be relevant for the plan sponsors?

Julia Croxen

Yeah. I think the direct to patient, strategy from pharmaceutical companies, especially as it relates to GLP ones, really opened up access to care for patients or consumers depending on how you wanna look at it and in twofold ways. One, it provided a channel by which to receive care services. So evaluation, treatment recommendations, and prescription, oftentimes from providers that have been trained specifically in obesity care. And I think everyone on this webinar likely recognizes the dearth of providers relative to patients in the US as a whole. That’s actually even more significant when you think about providers specifically trained in obesity care.

The other vein in which it opened up access is the pharma companies recognized that there was variable coverage as it related to GLP one medications among employers and payers. And this introduced a price point that for a a set of consumers was attainable, and they viewed the value of GLP ones providing them as kind of appropriate to the cost. It didn’t open up the the access for every consumer in the US in that vein. There’s, of course, sociodemographic considerations at play, but I think it allowed a number of patients who otherwise would not have been able to start a GLP one medication to find access and therefore increased the total treated population.

And we’ve seen that especially in some of the data that Zepbound has reported with about a third of patients moving through that cash pay model.

Jason Macaleer

Yeah. Yep. I think it’s like ninety five percent of the oral version of Wegovy is now is is being filled cash. I know we’re early, but but also, I think, resonates with what you’re you’re kinda pointing out.

So the the you know, this is just some eye charts here. I think, you know, the the takeaway that I see is is, again, around demand. Demand specifically for GLP ones, it has exploded, you know, five hundred percent increase in just the last few years. It’s continuing to rise.

For self funded employers, pharmacy spend, I think, just just tipped close to thirty percent of total plan spend. I think for context, it was somewhere below twenty percent just a few years ago. Not all of that increase is due to GLP ones, but but GLP ones were certainly a big contributor.

And if we assume about forty percent of the population is obese and could therefore qualify, you’ve got twelve percent of the population currently taking a GLP one. So the number of people who could be taking a GLP one is, like, three times higher than it is now, and that doesn’t account for the folks that have cycled on and off a GLP one, nor does it account for all the other conditions beyond obesity that GLP ones are indicated to treat. So really interesting just surge in demand. Right now, I think it’s about forty to fifty percent of self funded employers are are currently covering GLP ones for obesity. I think those that aren’t are trying to figure out ways to do so.

The good news is most of the employers are still covering GLP ones for things like diabetes and other less prevalent conditions. But but those that are are covering for obesity have sort of been forced to place some some pretty rigid restrictions on their coverage model that includes things like, you know, step therapy, prior authorizations, applying specific clinical criteria, cost shifting to members, and more just to make sure they can continue to cover the medications. And, Chris, to your point, it doesn’t sort of break the bank. So, Julia, as as you advise employers and health plans, what are some of the most common non price barriers you see limiting access to obesity care or obesity medications? And specifically, how do some of these restrictive benefit designs, like we just mentioned, potentially undermine the the the intended outcomes even when employers think they might be being fiscally responsible or doing the right thing?

Julia Croxen

Yeah. I think some of the real challenges are one is I already alluded to accessing care providers. I think another is the knowledge and, the ability to kind of maintain engagement with a holistic approach to weight management, which varies by individual in terms of what will work. I think as even the GLP one clinical trials have demonstrated, there is a component of behavior change and lifestyle that is really central to seeing the most significant outcomes.

And, we’ve seen GLP ones kind of be somewhat of a a kick start, if if you will, where patients, feel the the impact of the GLP ones in terms of the reduction of food noise quite quickly start to see the weight loss occur if GLP ones are effective for them, and that can serve as a reinforcing mechanism to then keep them on that path with their broader weight management strategy.

I think as you alluded to with some of those restrictions as it relates to step edits prior off and the like, can really reduce the patient, or member or employee motivation as it relates to kind of sticking to their weight management journey, which can in and of itself be be quite a significant challenge.

Jason Macaleer

Yeah. That’s a great point. I’ve heard a lot about, anti obesity medication, not just GLP ones, but but any anti obesity medication being sort of a catalyst for change. You start to see some of the early benefits, and that perpetuates the flywheel of, you know, lifestyle intervention and some of the behavior change and just really drives adherence. So really interesting. Chris, would would would love to get your perspective maybe on some of the coverage decisions that plan sponsors are making to keep GLP ones and other anti BC medications as part of their plan design versus carving it out. Maybe what have you seen driving interest in some of the alternative, you know, arrangements and models?

Chris Crawford

Yeah. Julia, I love what she said because it let’s talk about the current model as it exists. And so what a employer will do is put a prior authorization on the drug. Meaning, the member has to go through their system and upload their documents.

It’s based on some criteria. So it’s it’s not the person who’s given the care. Right? It’s just kind of a speed bump in the middle.

It frustrates the patient. It frustrates the doctor. And, basically, if you’ve met these criteria, then you get the drug approved and it kinda moves through the system. So one, members don’t love that, but two, employers are doing it because they’re trying to control utilization and say, okay.

We wanna have it be this way. So now if employers say they wanna put more limits on that so I’ll give you an example.

National and owned one of the most prominent health systems, you know, in the country talking through it, their team, you know, has obesity specialists and they’re prescribing, and they have a little higher BMI criteria for the members as they’re supporting them. That higher BMI means there’s zero rebate coming back for that plan. So you mentioned rebates, Jason. I think it’s important to know within kind of the traditional model how that works. How that works is if you are paying for one of these drugs, let’s say it’s Wegovy, the injectable, it’s fourteen hundred dollars.

And then maybe you get a rebate back from your PBM. And so that PBM could be bit or the rebate could be bit. It could be forty percent, fifty percent of the drug cost. But then you’re kinda managing if you do wanna do something different in utilization. Now you’re putting that cost at risk. You’re back to paying fourteen hundred dollars for a drug that somebody without insurance, anybody could go get from a hundred ninety nine dollars to three fifty.

That’s the cash price. So you’re kinda just stuck in this employer’s like, well, I don’t know, you know, what I’m supposed to do in this other than just try to control utilization because I feel like that’s my only lever that I have.

And so as an alternative, you know, when you think about the cash market, we kinda say this in, a tongue in cheek way a little bit, but it actually happens to be true. If a CEO went in and was covering these medications and they just said, we’re not covered anymore. I’m giving everybody the company credit card.

Go directly and just buy your medications from the DTC websites. Just buy them.

Employers would reduce their total spend on those drugs by forty to sixty percent overnight.

And so I think that’s the dysfunction in the system that’s kinda gotten us here, right, where you’ve got employers saying, wanna provide access. I’m being forced to buy through this kinda channel that isn’t really kind of working and kinda meeting my needs, yet I still wanna do it. What should I do? And so I think those are the challenges people are thinking about.

And I just wanna add, you mentioned the new pill from Wegovy. And I think that’s a really important case study to look at. So, Jason, I saw the same stat. Ninety five, ninety six percent of all oral Wegovy fills were direct to consumer, meaning they weren’t running through insurance.

The cost of those medications, if you buy them available to anybody, a hundred and forty nine dollars to two hundred ninety nine dollars. That’s the cost.

If you look at now PBM coverage, so one of the reasons is why is that number so high direct to consumer. It’s because everything still has to go through this rebate channel group purchasing organization. So the last I checked, I think there was one major PBM that did have it on formulary.

Other PBMs are saying, well, we gotta wait. We gotta go through our PMT committee. We gotta, you know, do all these kind of things. So members aren’t even getting access to that to that drug. And so now the challenge is what will that cost through the PBM? And if you’re on a high deductible health plan, so this isn’t just an issue for the employees or for the employer. If you’re on a high deductible health plan and you’re going to fill, and let’s say that drug is covered, you’re paying about thirteen hundred dollars out of your pocket for your first fill.

You could buy that same drug for a hundred and forty nine to two ninety nine if you skipped insurance. So I think it’s really interesting back to this point of, like, what does the DTC market does? It facilitates competition. We know exactly what the prices are, and that kinda leads to these employers looking and thinking about things differently.

Jason Macaleer

It’s a great call out. I actually may jump around here a little bit because we’re talking about some of the cash pay prices, and I think that was snapped into the national spotlight when the when kind of the Trump administration, the White House announced their GLP one price reduction. So there there seems to be a lot of attention from just a legislation and administrative standpoint around around affordable, you know, access to to certain therapies. And and and, frankly, you can’t open a web browser these days without seeing some new announcement that impacts the obesity space.

There’s been announcements made by CMS around new models like access and balance. If you’ve been tracking those. There’s the FDA announcing their their tempo program. MAHA’s got their elevate program.

But I think the most notable was the Trump Rx announcement from from kinda last November time frame. And and, again, the announcement was designed to help, I think, ultimately lower prescription drug costs by allowing consumers to purchase medications directly from the pharmaceutical manufacturer at these, like, discounted, most favored nation price points and and ultimately bypass some of the traditional kind of middlemen and just offer cash pay options for certain medications. And among those medications was Wegovia and Zepbound. And I think the result of this announcement is that the cash pay prices that were made available to consumers through the pharma manufacturers came down.

They saw a meaningful drop in what they were previously priced at to what they are now priced at. And so, Chris, you know, kind of piggybacking on maybe some of that commentary, you know, how do you think the announcement is is meaningful specifically for for those employers that are looking to take advantage of those cash prices, like you said? How big of a price cut did we see? Do you think we’ll see more?

And just how can how can plan sponsors maybe thoughtfully position themselves to take, you know, take advantage of some of these cash pay prices or lower cost prices or to your point, just more transparent prices?

Chris Crawford

Yeah. It it’s been really interesting to watch because in the traditional insurance model, we don’t really know what the price is. There’s a drug and they set it, but nobody pays that price. There’s a discount, and you get a rebate, and employees kind of think about their co pay. What are they paying? And then employers get billed the rest. So we don’t really have true competition or said another way, the competition might be dictated by the rebates that a PBM is receiving from one pharmaceutical manufacturer or another, which gives that drug a preferred formulary placement, and all of a sudden, we’ve kind of limited competition that way.

The direct to consumer market, what has been fascinating to watch is costs are coming down, you know, and so we’ve been doing this for a long time in the pharmacy world. How many times do you go, oh, these new drugs, these blast spectrum drugs, the costs are actually going down. Never happens. And so when you look at the direct to consumer when they started, the prices were four ninety nine, I think, basically kind of for all doses. Both manufacturers were there. Here’s the beauty about transparency, and here’s a good about some direct to consumer. You compete.

You compete on price and value. And I want Julia’s perspective on this, but I think you saw then prices going down.

And so then you saw kind of market demand. So if manufacturers like, hey, we need to have more sales, maybe we need to lower our price to get more consumers to come in. And so these prices have gone down from four ninety nine at where it started. And as an example, one of them is three fifty.

Another is four forty nine, but then there’s some lower doses there. And then forget about the oral pill again coming out. I just can’t underscore this enough. A hundred and forty nine or three hundred dollars.

Why? I can’t speak for the pharmaceutical manufacturer, but I think they see the other oral pill coming out later. They would like to get patients started on therapy now at an affordable price, try to get that market share so that you have people kinda in treatment. And so that’s how you lower your prices, and you have ninety six percent of your people buying directly because they get access because you can’t get access today through your pharmacy benefit manager. So headline is transparency leads to competition, and then competition leads to lower prices when we can actually see these prices.

Jason Macaleer

Yeah. And and timing, I think, to your point too around kind of market share and and and when things are scheduled to hit the market. Julia, I think that kinda ties into a question for you. And and, again, I can’t help but find the the timing of some of the Trump Rx news to be very curious.

It, you know, it happened at a time that sort of con it came just after plan sponsors had all locked down their plan designs for twenty twenty six, and most were kind of in or coming out of open enrollment. And so it’s just a really sort of curious timing of that, whether that was intentional or But why do you think the the pharmaceutical manufacturers agreed to these price cuts? I you know, there’s obviously a a Medicare component to this. But but how should we thinking how how should we be thinking about the the future of some of these direct to consumer models?

Are they are are there foreseeable risks that, that you can sort of point to if if you as a plan sponsor or as an employer start to assume that policy or legislation or even manufacturers are are gonna solve this affordability problem?

Julia Croxen

Yeah. I think speaking from the kind of hypothesizing of some of the drivers that drove the acceptance of the the price reduction with some of the, Trump Rx related announcements, I think a lot of what Chris already spoke to rings true. There was the recognition that they were already in a very competitive market just with the head to head between Wegovy and Zepbound. I think both manufacturers recognize that there are new entrants on the horizon with the oral now in market as well as, additional combination assets coming to the market in in the near future.

And the increase in competition would likely inherently have driven incremental pricing pressure and reduction. So this could be moving it forward, one might say, but I think there’s also recognition that with the the lowering of the price even to this degree, it further opened up the market and increased the number of patients that were willing to pay those the new cash rates, if you will, out of pocket. I think the points around Legovy oral pill, really ring true.

Novo reported kind of anecdotally that in the first four weeks, they saw about a hundred and seventy thousand prescriptions. As you’ve already alluded to, more than ninety percent of those were cash pay. But what I think is interesting is they’re also reporting that most of those patients are new to GLP one therapy according to their insights, which I think reinforces that idea of opening up of the market. And I don’t think all of that is attributable to it being an injectable. I think a lot of that is attributable to the lower cost. From the employer perspective, though, I think that there’s a risk in thinking that that just solves for for the problem of the cost. I think as we see the price go down, we’re still talking about forty percent of the population, which keeps the cost quite significant if you’re thinking about your, kind of, covered lives, if you will, or employees.

And I think that there’s quite a significant swath of the population for whom that the prices we’re at now and likely will continue to see in the near term are still out of reach or out of reach in a way that is sustainable. And most of the clinical data right now indicates that these are long term treatments. So even if you’re seeing a temporary impact in terms of obesity reduction, it might not be sustained if there’s an assumption that you’re expecting your employees to to continue to to pay out of pocket, to pay the cash pay rates.

Chris Crawford

I wanna build on that because it’s such important points. So what we see anecdotally is when a person has to pay two hundred or more out of their pocket, we have about a fifty percent walk away rate. Meaning, have a prescription that’s ready. I just can’t afford to fill it, and I’m not gonna fill it. I’m gonna walk away.

As Julie’s point, what that does not take into account is the people who say, well, I could afford two hundred maybe for two or three months, but I should really be on this drug for ten or eleven to get there, but I just can’t afford it. I can’t do it. Then they go off, and it’s almost like, how have those dollars been wasted because you didn’t get the full treatment or people are coming off and on treatment? So this whole point of making it affordable to people is really key.

But then, Julia, you know, I’ll translate what you said a little bit for employers because, like, hey. This is great. These are new people on the pill that weren’t on the injectable. The translation for employers, that’s new utilization that you weren’t seeing before.

Right? So that’s more utilization back to that hockey stick, which is okay. Now how do we address that? What is that drug gonna cost, you know, as we run it through insurance?

How does that compare to the cash rates? Because I do agree. I think the thought is people will prefer the oral pill, and then you’re gonna open up this whole new kinda aspect of the market if people wouldn’t have would have considered the injectable. But now with the pill, they may be more willing to kinda build this into their daily routine.

Jason Macaleer

This is such an interesting conversation. I I think for context, it’s only about five percent of oral pill users were previously using an injectable. And so, like, very little cannibalization with the oral version. And I think to your point, price has a big part to do with it, but then it opens up this utilization and access piece.

I flipped to a slide, and I apologize because I’m kind of jumping all over the slide deck here, but I love where the conversation’s going. This is a look at the obesity medication pipeline. And, Chris, I think some of this ties into what you were talking about, timing and trying to capture market share. But what to me it speaks to is two twofold.

Number one, there are a a ton of of new obesity medications that are going like, scheduled to hit the market.

The oral version of Wego, we we sort of, you know, beat that horse a little bit. But, you know, that’s a evidence right now in clinical trials suggests, like, a thirteen percent weight loss at the twelve month mark, thirteen percent, fourteen percent weight loss. That’s now also that’s now kind of in market. You also you see some of the other medications that are scheduled to hit the market later this year.

You’ve got Novo and Lilly both offering additional types of obesity medications. Boehringer’s looking to to enter the market with their version of a GLP one. And while it’s not mentioned on this slide, you’ve got retreotide, which is the triple agonist, that’s promising upwards, I think, of, like, twenty four percent weight loss at at at at twelve months and and, again, targeting that twenty twenty seven, release date, hopefully, with with clinical trials coming to close. So the category of obesity medication is gonna get really crowded, I think, fairly quickly.

And then you’ve also got more indications for which these medications are being approved. Right? The FDA is now, I think, as of today, approved GLP one therapies for type two diabetes, for obesity, for MACE, which is adverse cardiac events, for obstructive sleep apnea, and for MACE, which is a type of fatty liver disease. So that’s today.

But then you can also see here on all the other indications that are likely coming with addiction and substance use disorder and osteoarthritis and acid reflux and more and more and more. And so I think more medications coupled with more conditions only underscore the need for plan sponsors to have a strategy in place. And and, Julia, like, again, I’m gonna kinda circle back to you a little bit on this. I would love your take on how plan sponsors can be preparing for some of these new therapies and new indications.

What are the opportunities? What are the challenges that you could see arising, and how could it help shape plan design? And I’m gonna use an example, It’s a nefarious one, so I apologize, but bear with me. Not to assume worst intent, but if I if I if I am a health plan and I today choose not to cover GLP ones in any way, shape, or form for obesity, With all of these new indications, could I, as a member and somebody who desperately wants to be on a GLP-one, go pursue a diagnosis for something like obstructive sleep apnea that is indicated for a g l p one as a way to make sure my g l p one gets covered by the health plan.

Right? Is these sort of these, like, backdoor loopholes? And if so, like, what’s the right what’s the right way for plan sponsors to be thinking about that? Again, I’m not suggesting that’s going to happen, but just, like, what’s the what’s the right way for plan sponsors to be thinking through that a little bit?

Julia Croxen

Yeah. I think that’s a really interesting, kind of consideration.

And I think it’s interesting for the plan sponsor to even consider the added cost associated with the the diagnostic journey, if you will, to reach some of those or to receive a diagnosis for some of those comorbidities or other ancillary chronic conditions that are often comorbidities, I will say, alongside obesity.

There are many which are underdiagnosed and undertreated today, which do have downstream outcomes and cost implications when they’re uncontrolled for the patients, of course, and then also the plan sponsors.

I think that there’s opportunity to think really intentionally about some of that long term cost benefit and cost reduction if you are able to treat obesity and prevent some of the comorbidities from kind of coming into play at all, or from becoming exacerbated such that they become higher costs. I think that the advent of more options also allows for opportunity to introduce more of a precision approach in terms of the care paradigm and also the coverage paradigm for plan sponsors where they can more intentionally match specific patients to specific treatments, both considering anti obesity medications or the right GLP-one or GLP-one combination asset, we do see individual patients anecdotally being more responsive to one brand versus the other, or being able to switch from one brand to the other after reaching a plateau in their weight management journey.

So thinking critically about the clinical paradigm, I think alongside the cost, and ROI paradigm could really unlock opportunities to ensure that you are seeing ROI if you do choose to cover for obesity.

Jason Macaleer

Great. Chris, anything you’d add to that?

Chris Crawford

I just think this is such an important slide. So I think one of the questions people have is, will this pass? Is this two GLP one thing? Okay. We’ve kind of figured it out. This won’t be that big of an issue for that long.

And I think, you know, what this slide shows is the new options. And I also think really interested, Julia, I think much more qualified to answer this than I am, but it’s like, where are pharmaceutical manufacturers investing? You know, that’s kind of where they’re investing are the next expensive drugs that employers are going to have to pay for. So if you follow that logic and the notable deal, I think everybody price all Pfizer paying, what was it, Julia? End up being ten billion?

Julia Croxen

Ten billion, roughly.

Chris Crawford

Ten billion. They got no price war and all these things for a company called NetSerra that had a very other things too, but a very promising weight loss piece. Julia, don’t know if you want to speak to that. And then what the return is that these companies expect when they’re paying for a company or they’re developing a drug when it goes to market. You know, how that works is, again, I think where they’re investing, where the drugs are gonna come to market are gonna be the things that are in demand then for employees when they’re looking at it, and so it brings more decisions to the employer.

Julia Croxen

Yeah. And we do see pharma continuing to double down on investing in GLP ones and associated combination assets kind of across their pipeline from early phase one, phase two, all the way through phase three. I do think the acquisition is very notable. We also see both large pharmaceutical manufacturers investing as well as biotechnology companies kind of looking to to Metcera as that example of a potential path to market exiting into a a larger pharmaceutical manufacturer.

I think in addition, we see a lot of investment across disease states as it relates to clinical trials in terms of indications of use that could prove out to be that GLP ones could prove out to be impactful for. Folks continue to invest and discuss Alzheimer’s even following kind of negative trial results last year. So just because one asset fails to produce, the outcomes expected in a certain indication doesn’t necessarily mean it’s off the table. And many of these indications are also highly prevalent as it relates to the US population, especially looking at things like, substance use disorder, like Alzheimer’s, etcetera, to back to Jason’s point, just continuing to open up the potential in terms of the treatable population.

Chris Crawford

Yeah. Let me let me just add one point to that too, just back to the to the Pfizer piece. You know, it was interesting of the timing of the acquisition announcement was very close to the timing of Pfizer supporting Trump Rx and the direct to consumer and their direct to consumer prices as well.

So I think now it’s Julia, what is it, fourteen, I think, of the seventeen major manufacturers have all committed to doing direct to consumer prices? Is that number right?

Julia Croxen

I believe that’s correct now. But adding to the list often.

Chris Crawford

Yeah. So the point being right, this isn’t just these two drugs or something else. It’s more and more that’s coming out there to support that and essentially get this. Well, if if we have to pay a rebate through a PBM owned group purchasing organization, can we just basically take those dollars that we were giving there, provide a net price, you know, directly to the public, and let’s sort of see, you know, what happens? And I think that’s really what we’re seeing these DTC prices as well.

Jason Macaleer

Yeah. It’s one of these things where I think it’s can run, you can’t hide just given all of the attention, the pipeline, the indications. I think just it underscores the need for a strategy and and a a more comprehensive strategy. And then, Julie, I think to your point around some of the wraparound services and and bringing a holistic approach, it’s not just the medication.

It’s not just the cost of the medication. And it’s sort of a segue into this three legged stool slide here, and I will own the the production value here on this. It seems very Microsoft pain, but but that’s on me. So from the the plan sponsor standpoint, you know, these are kind of the three primary levers, I think, that can be pulled to help control plan spend when it comes to obesity care and the medications.

Expanded access, that’s, you know, pretty self explanatory. How many people who need obesity care or need a specific medication can get it.

The unit cost piece, Chris, this is what you keep underscoring is, like, what is the actual price I am paying for my obesity service or medication?

Like, net of any rebates or, you know, just on a transparent basis, what is the unit cost I am I am paying for that service or that medication?

And then ultimately, outcomes. I think this tends to be overlooked, which is, you know, ultimately, are the outcomes that that are being achieved and sustained with the obesity obesity care program or or those medications? As I mentioned, you know, obesity care and medications are a bit unchartered territory right now just because, you know, if every plan sponsor were to fund the ten thousand dollar per member per year medication for forty percent of their population, it would bankrupt most plans or or force them to raise premiums to some unfathomable level. So there’s this conundrum, I think, that exists for those plan sponsors who genuinely believe in the benefit of an obesity management program, including GLP one therapies, and have chosen to cover those those drugs and those programs and continue to cover those programs, but but then are wrestling with sort of the cost piece.

And so I believe most plan sponsors don’t view sort of coverage as binary, meaning I don’t think they look at this as an all or nothing. Either I cover obesity management and the drugs, or I don’t. I think the challenge becomes, how do you make sure there’s clinically appropriate access to people who need it?

And I think that’s the fundamental question that’s become a core part of most of these plan design strategies and certainly the conversations I’m having. I think the assumption we all make and it’s really where I want to spend a little bit of time here is when it comes to covering obesity medications and obesity management programs, management programs, there’s an expectation around outcomes, clinical outcomes, whether it’s adherence to the medication, whether it’s weight loss for those that are on a medication, whether it’s a reduction in cost of care eventually for those that are engaged in that therapy or that treatment. I think the assumption is that those programs and those medications are working as designed, and members are seeing the benefit. We talked about cycling on and off.

But, Chris, this question I’m taking the long road to from your perspective is is just this piece around affordability and the barriers that tend to show up in real life. What do what do plan sponsors tend to maybe underestimate about the friction people face when trying to get access to certain medications or treatment? Is there this thought that if we don’t cover them, they just won’t get them? They won’t find their way to them? Or is there another angle here that maybe needs to be considered?

And if I can just build on that a little bit more, where have you seen some of the employers and and your clients rethink the cost controls they have in place that that preserve that access instead of, like, restricting it?

Chris Crawford

Yeah. Yeah. So I think your slide is amazing, Jason, that you put together. So let’s focus on unit cost savings at the bottom left.

And this unit cost savings is a big one, and it’s a big one because you also have to turn the lens from a fiduciary responsibility for the employer. So we’ve kind of forgotten maybe a little about because there was lawsuits that happened a few years ago, and it was on overpaying for prescription drugs basically through your insurance plan when a transparent lower cash price existed that somebody would be better off skipping their insurance and paying cash. Now in that case, that was, you know, generic drugs, biosimilars, and they were really using a reference of this generic medication that was costing thousands of dollars through your insurance when that same person without insurance could go to Mark Cuban’s Costco’s drug company and buy that drug for twenty bucks.

But the concept was known prices as a fiduciary. I am responsible for managing my plan assets at my company.

How can a prudent fiduciary pay this much more compared to the cash prices? That was the entire lawsuit piece. Right? And so now you look at this with these drugs and the emergence of the DTC prices, and the situation is the same.

How can I, as a prudent fiduciary managing my plan assets, knowingly pay so much more for these medications when somebody without insurance could go pay less when you go through? So I think it’s it’s forcing, you know, a tough conversation, you know, for employers, which is like, well, why can’t I access those prices? You know, we have all these employees. We have all the we should have leverage.

Right? And they’re kind of stuck in this leverage is actually leading to more. So, Jason, to your point, yeah, they’re rethinking this totally. Like, if that price exists, how can I access that price to still get, you know, folks the care that they need to still make it affordable so they can do it?

But it’s hard for me to do both, you know, into the traditional framework of what these medications cost through the traditional channels.

Jason Macaleer

Super interesting.

To me, that that’s kind of a segue into these, like and and, Chris, I might ask you maybe to continue that. And and and I don’t want this to necessarily read like an RxSave card commercial, but I think the way that you are bringing sort of thoughtful approach to the member responsibility and then the fiscal responsibility to the plan sponsor and the the control or maybe the choice that you enable through x Rx save card is really interesting. And, yeah, we talk about some of these different payment models that are being explored right now, some that allow for lower cost, all that allow for more transparency.

You know, ideally, there’s there’s partners that you can you have in your ecosystem today as a plan sponsor that do this. But but if you’re doing things more off formulary, I think this Rx save card model is really interesting, specifically as it pertains to lowering out of pocket costs for members without shifting, like, an unsustainable amount of risk to the employers. So can you talk specifically maybe what that subsidy looks like, the cost share or cost structure looks like around this kind of Rx save card model? Because I think it’s really interesting, and it and it fills a a real need right now.

Chris Crawford

Yeah. So your your point’s a good one. It’s, hey. We’re taking this off benefit. So we can’t afford to kinda do it through the normal normal channels.

These DTC prices exist. Well, what should we do? And I think there’s two places. So one is the most important getting the person the care they need.

Right? So like that’s that’s your sales pitch, you know, Jason going through Vita, how we’re getting people to care, we’re making sure they’re supported, making sure they’re kind of getting those meaningful choices. Now, but if you do that and the person can’t afford the medication because we’ve taken it off formulary, then we haven’t achieved success, right? So somebody can’t afford that four fifty or the three fifty or whatever it is.

And you’ve got fifty percent of employers who aren’t covering the medications.

So, you know, there’s this other way where if I was an employer, you kind of think like way back when if you were doing wellness challenges or something else, like, oh, we’ll give you a couple hundred bucks towards a gym membership, or companies doing things on lifestyle accounts. So there’s this concept of like, hey, You meet these steps. We wanna help you use these dollars as you wanna do it. Right?

And so those concepts are like, well, why can’t that also apply to if you’ve gone through your weight loss journey, instead of getting those dollars for a health club membership or something, let’s, you know, help you afford this medication. Right? So everybody wants affordability. People don’t wanna overpay when you see those prices.

There is this different model, and I’ll just go back to, like, where we started. It’s like if you just gave everybody a credit card. So RxAir card doesn’t exist. Right?

Employers, just just go. Do this, and you’re gonna see your costs go down. So there’s this in between step where these cash prices exist. It’s all formulaic.

Let’s figure out a way to make it affordable, you know, for these folks in a way that’s sustainable and allows us to actually give the coverage to folks that they need because they’re just struggling to afford it otherwise.

Jason Macaleer

Yeah. Yeah. Again, I to me, that serves a real need right now. And and, Julia, I may may pick on you one more time to just maybe try to tie together in your mind’s eye as you, you know, as you know this space really well.

What would separate, like, a really good, smart affordability model like this with one that could create more administrative or or financial risk, right, to the plan sponsor. Like, sometimes, like, the juice ain’t worth the squeeze type of thing. This juice seems very worth the squeeze, but I I just wanna make sure we reconcile any, administrative or financial risk to the plan sponsor. If you could just maybe speak to that.

Julia Croxen

Yeah. I think some of the administrative risk with some of the more traditional management steps really are associated with some of the the overhead in executing on things like step edits and prior authorization. And I think many plan sponsors might say, well, we we have AI now, and we can’t have a innovation oriented, webinar without mentioning AI. But, if you also look at health systems and providers are increasingly using AI to navigate some of those, step edits and prior authorization. So I’m I’m not sure how that will all net out in terms of kind of who wins out the AI battle as it relates to to some of the rev cycle aspects.

But I could see a world in which those traditional models become less effective for utilization management, which is a risk in and of itself as the the AI model supporting from both sides of the table just get better and better, and instead are just delaying some of that cost as opposed to really effectively managing or preventing it.

Jason Macaleer

Yeah. Yeah. That that I think that’s well said. It it kinda tees up this this next slide, which is why I advanced while you were talking.

But, you know, one of the things I wanted to highlight was, you know, hey. What what is working? What’s an alternative model and an alternative strategy that is working well in in market? And so if you guys will just allow me a few minutes to kind of walk through why I think this kinda comprehensive model makes sense, both from a both from a cost savings and afford affordability standpoint.

But also, Julia, to your point, like, without introducing unnecessary complexity or administrative risk or even some financial burden, still, like, capturing the benefits of both worlds. So to me, flexibility is is key to any good, like, obesity management strategy. And so this kind of walk through is is one strategy in particular. There are others, but this one to me makes a lot of sense because it brings flexibility in its design.

It also happens to be working really well, but it weaves together the best of all of the three legs of the stool, access, lower costs, clinical outcomes. And it does that into this cohesive member experience that can be tracked and can be measured closely by the plan sponsor. And that tracked and measured closely part, I think, is typically what has been missing from these cash pay models. They tend to be that *** ***** hole of, like, I don’t know what who’s buying what on these cash pay models. And so that that closing of the loop becomes really important. So the first part of of, you know, any good obesity management strategy, but but certainly this one, is enabling the plan sponsor, these employers, to have more choice in setting their own rules. Right?

And setting their own rules could be offering employers the ability to set their own budgets or cap their own spending limits, set their own goals from this program, their own criteria, their own participation requirement for members around behavior change, and things like that, but allowing for more choice.

And then and and not be not be at the mercy of a third party, an f the the FDA or some third party in their ecosystem, but it gives them more control, more choice over over that program. That choice allows the sustainability of the effect of the obesity management program and ultimately that strategy. But it allows the the dollars to be used smarter and how the plan sponsor wants to to deploy them. So setting the rules is a big part of this.

Then there’s adherence to clinical protocols. Any good obesity strategy, especially one that’s prescribing medication, should be following some evidence or literature to make sure they’re delivering appropriate care. The safety and efficacy needs to be paramount. And to be clear and, Chris, I think you kinda touched on it.

This is much different than having prior authorization and utilization management controls in place. This is where a provider or a care team who is delivering care remains involved throughout the obesity journey. Right? They work with the member in concert with the member within a design that the member appreciates and can buy into that meets the needs of that member.

So this is not, hey. I’m a third party. I say yes or no, and then I kick you back into the system. This is a care team delivering clinically appropriate care throughout the journey.

And it’s really important that we highlight that. It tends to be overlooked or undervalued, but that clinical care team is engaged from start to finish. Right? They’re working with the member, supporting the member, empowering the member, especially as sometimes different medications and medication regimens are introduced.

That progress gets tracked. Improvement gets measured. But developing those care plans that are tailored for the unique needs of each member, including medication, that’s critical to make sure outcomes are both achieved but sustained. Right? All the literature will tell you the best medications don’t work if you don’t have the behavior change to go with it. They will be sort of interim results that regress to the mean or regress to sort of the starting point if they don’t come with behavior change. So to me, the clinical protocols has to be a core part of any good obesity management strategy, making sure you are appropriately delivering care, including medications, to those who are most appropriate.

And then, Chris, I think, you know, we kinda talked a little bit about this already, but this savings card piece, which is the way plan sponsors can fund obesity care, obesity medications, the flexibility in the dollars that they can set aside and and use for obesity medications, the limits they can put in place, the flexibility in how and who can access those dollars. I think this is really, really important. The cash pay channels make sure you’re you’re obtaining the the lowest available prices for these medications and maintaining that fiduciary responsibility without sacrificing access to the members. So bringing this all together, and it only got about five, six minutes left, is to me, it is it is not any one part of this program. It is the program used kind of in in concert together as a as a as a total end to end member experience.

So that’s kind of how I think about these these alternative models. Yes. You there’s ways you can take advantage of cash pay prices, lower cost prices. There’s ways that you can bring reporting and visibility and transparency into this, and you can do that without throttling access and maintaining that clinical appropriateness that I think will drive behavior change that will ultimately lead to sustained results. So that’s a little bit of my commercial. But, you know, Chris, Julia, anything you guys would add to that?

Chris Crawford

I can go first. Just the clinical protocols is so important because I or ask it another way. You know? Like, how many employers are generally happy the way the current system works?

Or how many employees that need access to their medication are happy with the current system or the way it works? I think you just see frustration around, but like the prior authorization that put in is a, we have to do something to control utilization. But your point is like, that’s not getting me care. That’s saying deny, go back and talk to your doctor about something else.

Or that’s saying, no, you won’t get access to these drugs because these are the ones we have on formulary. You can’t get access to this one. They’ll work better. So I think when you kinda take the approved deny out and talk about supporting the member and the physician is involved in getting the right medication, And now once you’re ready for that right medication, we have this robust cash market where you can access and you control the cost piece well.

I think that’s where you’re putting these two things together. And it just it becomes a whole different model, which I think people are hopeful for, you know, in the future of like, hey. Could we do this to other disease states as well? What are the categories, you know, could this work with as we think about getting out of approved deny and getting out of, you know, caring for the member with the availability of transparent prices?

Jason Macaleer

Absolutely. I think that’s well said. And Julia, would love your point of view on this, especially around sort of this like integrated care model where you’ve got medical oversight, you’ve got nutrition, you’ve got behavior change, all that kind of wraps into this service. Medication, obviously, being a big part of it, but would love how you view it as as kind of all coming together. And and and frankly, you had mentioned kind of those that start and stop medications and how that can create long term issues and maybe how this can help remedy or reconcile some of that.

Julia Croxen

Yeah. I think that’s one of the the most important pieces. I think it’s twofold. I think that wraparound support, especially from the the clinical oversight, really helps to set expectations for patients as they’re getting started in terms of what could be some of the side effects that a patient may or may not experience.

What will it be like to use an injection on a weekly basis or an oral on a daily basis? What should they expect in terms of weight loss? What are the safe bounds of weight loss? What’s weight loss that’s too much and too fast?

How can they prevent or manage some of the side effects, either that come alongside drugs or alongside just losing weight? And I think those are really important elements at the outset and throughout.

And ultimately, that behavior change, that lifestyle support really does help kind of as this slide is alluding to, to see the greatest effectiveness in medication use as a weight management tool.

And should a patient one day decide to to titrate off, I think anecdotally, we’ve seen that those that have complemented GLP one treatment with lifestyle behavior change are more likely to see durable effects than those who have kind of purely taken an AOM or GLP one approach.

Jason Macaleer

Yeah. That’s exactly where my mind went. I know we’ve only got a minute left. And I think, you know, whether you’re talking about behavior change alone, a low cost anti obesity medication, or a GLP one, any effective obesity strategy should show these similar lines, like downward trending lines.

I think a truly comprehensive strategy or program needs to be able to do all three do all three well. I think GLP ones, as we talked about at the top, are a great way to get members to a specific goal and potentially faster. But like I said, I think we we’ve seen most members care less about the number on a scale and more about how they feel and being able to maintain those results. And that feeling over time is what’s most meaningful.

That’s how you make sure those dollars are spent appropriately and wisely and that there’s a return on those dollars. So I I know we’re at time. I only saw one question in the in the chat, and that was, I think, more for for Chris. If we’re seeing, you know, clients that are adding some of these Rx benefits to the preventative drug list that would negate the deductions on the high deductible health plan.

If you wanna maybe just round out that answer, I think we can wrap.

Chris Crawford

Yeah. That wouldn’t be through Rx Savecard because that’d be covered under the plan, under the benefit. And, yes, we did see some employers doing that. The the ones I did see do that have changed that because I think the utilization was really, really high of of what they were seeing. So the ones that I have seen that are rethinking that a little bit.

Jason Macaleer

Perfect.

Perfect. Well, that’s our time. I want to thank Chris, thank Julia for thoughtful commentary and for the insights. It’s been really helpful. I think we can probably share and distribute slides to the audience if it’s if it’s desired, but really appreciate everybody’s time.