Demand for weight loss medications continues to surge and shows no sign of slowing down. When GLP-1s first made headlines, many were concerned about the safety and efficacy of these products. Now, the conversation has shifted from safety to accessibility, with millions of Americans looking for ways to get their hands on weight loss medications.
Gaining access to these sought-after medications continues to be an issue. Significant shortages upon launch, in tandem with the entry of compounding pharmacies into the market, have created significant barriers for patients seeking FDA-approved treatments. In response, manufacturers Eli Lilly and Novo Nordisk created their own platforms for patients to access their branded products, Zepbound and Wegovy, through cash-pay models. These direct-to-consumer (DTC) platforms have sparked considerable discussion amongst employer groups, as plan sponsors continue to determine whether or how to cover these medications under their pharmacy benefit.
How DTC programs can help the right patient
Despite recent attention, DTC platforms are not a new concept. As early as the mid-2010s, manufacturers such as AstraZeneca offered medications like Nexium directly through the manufacturer’s website. However, the rapid uptake of weight loss medications has brought renewed visibility to these models. Today’s DTC platforms promise greater pricing transparency, potential discounts, virtual provider consultations and home delivery of prescribed medications. These options are attractive for those who are under or uninsured or living in rural areas with limited access to health care providers. Through bypassing insurance, DTC platforms offer an alternative pathway to treatment outside of the traditional pharmacy benefit, sometimes at a lower upfront cost to the member.
Why DTC programs might not always be the best option
It’s important to keep in mind that these platforms are not without risk. While they are intended to address existing gaps in access and affordability, DTC models may inadvertently widen health disparities. Accessing medications through manufacturer-run platforms requires reliable internet access, adequate digital literacy and the ability to pay out of pocket. Although prices for obesity medications have declined over time, affordability remains a challenge. Currently, LillyDirect offers Zepbound at approximately $299 to $449 a month, while NovoCare lists Wegovy at $149 to $349 per month. To put it in perspective, the average annual out-of-pocket health care spending in 2023 was $1,514 per person. Even at the lowest monthly price point, a full year of treatment would exceed that average, still leaving treatments financially out of reach for many patients despite recent pricing improvements.
Beyond cost considerations, DTC access also raises important safety concerns for plan sponsors. When medications are obtained outside the pharmacy benefit, visibility into a member’s full medication profile may be lost. Because these fills bypass pharmacy benefit managers and often fall outside traditional pharmacy and provider workflows, pharmacies and primary care providers may be unaware that a patient is taking weight loss medications. If members fail to disclose that information, the risk of drug interactions, duplicate therapy or unmanaged side effects increase. For plan sponsors and members, this lack of clinical visibility introduces both patient safety and care coordination challenges that warrant careful consideration.
As these DTC models continue to evolve, manufacturers are no longer the only players shaping this space. Since the launch and uptick in utilization of the NovoCare and LillyDirect platforms, more platforms have emerged with broader ambitions. Rather than offering access through a single manufacturer or for a single disease state, DTC platforms such as TrumpRx and America’s Medicines aim to aggregate manufacturer programs and expand access by working directly with multiple manufacturers. These models represent a shift toward broader, market-facing pharmacy platforms that may further disrupt the traditional pharmacy benefit structures.
Areas of opportunity and risk need to be considered
Directing members to the DTC offering may reduce overall costs to the plan and limit the need to provide coverage or oversight of certain therapeutic classes. For members who would not meet coverage criteria, these platforms may provide an alternative pathway to access treatment. However, these benefits must be weighed against the concerns related to visibility into medication use, increased fragmentation of care and heightened member confusion, particularly when these medications are accessed through multiple manufacturers or platforms. One of the biggest concerns to keep in mind is that since DTC purchases do not flow through the pharmacy benefit, associated costs do not count toward members’ deductibles or out-of-pocket maximums, which may inadvertently increase a member’s total health care spending depending on comorbidities and long-term needs.
In response to these limitations, a new access model has emerged that is designed specifically for employers. These direct-to-employer (DTE) offerings, including those recently announced by Waltz Health and 9am Health in partnership with Novo Nordisk and Eli Lilly, are specifically designed for employers who do not currently cover obesity medications under the pharmacy benefit today. These approaches would bypass the PBM and require employers to carve out GLP-1-based obesity medications from their benefit, but promise fixed, pre-negotiated pricing. This may result in lower and more predictable net costs for employers; however, it may also require the employer to pay additional fees to third-party vendors. Third-party vendors, like Waltz Health and 9am Health, help to support these models by combining pharmacy navigation with holistic weight management support.
As access models continue to expand beyond the traditional manufacturer-led platforms to broader market aggregators, plan sponsors will need to thoughtfully assess how these DTC and DTE options align with their overall pharmacy strategy and commitment to equitable access. Proactive evaluation, clear member communication and guidance will be essential to ensure that the DTC models support safe, coordinated and sustainable care.
The Employers Health clinical team remains committed to supporting employers and their members in understanding the nuances of these evolving offerings and welcomes the opportunity to address any additional questions at [email protected].
