Evernorth to Cap Out-of-Pocket Cost for Wegovy and Zepbound at $200

Evernorth is offering the weight loss drugs Wegovy (semaglutide) and Zepbound (tirzepatide) to patients at a monthly cost of no more than $200, which will also count toward patients’ deductibles. Patients can save as much as $3,600 per year compared with direct-to-consumer manufacturer programs, Evernorth said in a news release.

Additionally, the PBM said that the prior authorization processes will be simplified and automated for faster access, and patients will be able to access the medications through a network of local retail pharmacies or through home delivery through Evernorth’s EnGuide Pharmacy.

Health plan sponsors will see a significant reduction in the net cost per prescription of GLP-1 medications, according to Evernorth.

Evernorth executives say they are able to offer products at this rate because of direct negotiations with the medications’ manufacturers. In recent months, the pharmaceutical companies — Novo Nordisk, Wegovy’s manufacturer, and Lilly, Zepbound’s manufacturer — have launched new programs to increase access at a lower cost.

For example, Novo Nordisk launched NovoCarePharmacy in March to provide direct-to-patient shipments of all dose strengths of Wegovy at a price of $499 per month. Additionally, Novo Nordisk updated the Wegovy savings program to allow patients to access the lowered cost of Wegovy at retail pharmacies. The company is also working with Hims & Hers Health, LifeMD and Ro to allow access to these patients through CenterWell Pharmacy, which is the dispensing pharmacy managing prescription fulfillment and delivery for NovoCare Pharmacy.

Earlier this year, Lilly lowered the prices of several Zepbound (tirzepatide) doses for patients using the company’s self-pay program. Through a new program, the Zepbound Self-Pay Journey Program, self-pay patients with obesity now have additional options to purchase the vial presentations of Zepbound, including 2.5 mg, 5 mg, 7.5 mg, and 10 mg doses. The new program provides reductions on prices on some doses of Zepbound vials, but not the autoinjector pens.

Payer Concerns

Related: Payers Consider Policy Options for Access to GLP-1 Obesity Medications

Payers have struggled to provide access to affordable obesity drugs because of their high prices. In a recent survey, 27% of employers reported GLP-1 drug costs to be more than 15% of their annual claims.

The survey, conducted by the International Foundation of Employee Benefit Plans, found that 55% of employees surveyed provide coverage for the GLP-1 therapies for diabetes only, which is down from 57% in 2024. Additionally, 36% provide coverage for both diabetes and weight loss, which is up from 34% in 2024. Of those currently offering GLP-1 drug coverage only for diabetes, 17% are considering offering the drugs for weight loss, which is down from 19% in 2024.

Julie Stich

“Organizations are balancing the ongoing demand from employees for GLP-1 coverage for weight loss by continuing to explore feasibility through cost-control mechanisms,” Julie Stich, vice president of content at the International Foundation, said in a news release.

The demand for GLP-1 drugs such as Wegovy and Lilly’s Zepbound (tirzepatide) for weight loss is increasing. A PwC survey in October 2024 found that 8% to 10% of Americans are currently taking GLP-1 drugs, and 30% to 35% of Americans are interested in using them.

According to the International Foundation survey, of those employers that cover GLP-1 drugs, 78% are using utilization management as a cost-control mechanism; 96% require prior authorization and 26% require reauthorization for refills.

Eligibility requirements, used by 68% of employers covering GLP-1 drugs, continue to be heavily relied upon as a cost-control option, with a minimum body mass index being the most common.