Federal employees and retirees who use GLP-1 weight loss drugs through the Federal Employees Health Benefits (FEHB) Program should expect tighter prior authorization rules and higher prices next year, NARFE News reports.
Key Facts
- Usage is widespread. Roughly 1 in 8 Americans uses a GLP-1 drug for weight loss.
- Costs are driving spending. The price of these medications has fueled rapid growth in FEHB pharmacy spending.
- Premiums have jumped. FEHB enrollees have seen sharp premium increases over the past couple of years, with GLP-1 costs a major factor.
- Changes are coming. NARFE reports that prior authorization changes and higher prices are expected next year.
- Out-of-pocket impact possible. The changes could affect both coverage decisions and what enrollees pay at the pharmacy.
What Prior Authorization Means
Prior authorization requires a plan to approve a prescription before it covers the drug. Plans typically set criteria a patient must meet, and a prescription can be denied or delayed if the criteria aren't met or the paperwork isn't complete.
Specific requirements vary by FEHB plan. NARFE's reporting does not detail each carrier's criteria, so enrollees should confirm the rules with their own plan.
What It Means For You
If you currently take a GLP-1 drug, or are considering one, check your plan's formulary and prior authorization requirements before you renew or switch coverage.
- Review plan brochures during Open Season. Brochures from each carrier outline drug coverage, tiers, and any authorization requirements. Open Season typically runs from mid-November to mid-December, with new rates published by OPM ahead of it.
- Talk to your prescriber. Your doctor's office may need to submit documentation to your plan, and changes to criteria could affect existing prescriptions.
- Compare total costs, not just premiums. A lower-premium plan may carry higher drug costs, and the reverse. Use the FEHB value guide to weigh premiums against expected out-of-pocket spending.
- Confirm pharmacy details. Check whether your plan requires a specific pharmacy, such as a preferred network or mail-order option, for specialty or high-cost drugs.
Context
GLP-1 medications were originally developed to treat type 2 diabetes, and several are now also prescribed for weight management. Demand has grown quickly, and the drugs carry high list prices. Because FEHB is a premium-based program in which carriers' costs are reflected in future rates, rising pharmacy spending can show up in what enrollees and the government pay.
NARFE did not provide plan-specific figures for next year's price or policy changes in the information available. Enrollees should rely on official plan communications and OPM announcements for final details.
Source: NARFE News