Cigna's Evernorth caps yearly GLP-1 spending growth at 15% for participating employers

Evernorth Health Services, part of The Cigna Group, introduced a financial guarantee on March 7, 2024 that limits how much extra employers and health plans in its EncircleRx program pay for GLP-1 medications from one year to the next, holding the increase to 15% ^[1][2]. Evernorth said it was the first guarantee of this kind offered to clients that cover the drugs ^[1][2]. Clients may choose either the cost cap or a savings guarantee ^[1].

The cap is possible because of agreements Express Scripts reached with Novo Nordisk and Eli Lilly, the makers of Wegovy and Zepbound, and Cigna has not released the terms of those contracts ^[2]. Those two products carried monthly list prices of $1,349 and $1,060 ^[2]. Cigna said the guarantee applies to spending on Wegovy and Zepbound ^[2].

For comparison, a Cigna spokesperson said the yearly cost trend health plans face for weight loss drugs has been running at 40% to 50% ^[2]. "It's a completely unsustainable number and our clients continue to look to us for help," Adam Kautzner, president of Express Scripts and Evernorth Care Management, said at the insurer's investor day, held the day after the announcement in New York ^[2]. In the announcement itself, Kautzner said the guarantee gives employers and health plans "greater predictability and control of their GLP-1 spend" ^[1].

Terms differ by client. A Cigna spokesperson told Healthcare Dive that each company's specific guarantee depends on its type, its current benefit offerings, the size of its patient population and other factors, including the client's financial strategy and preferences ^[2].

Medication is paired with a lifestyle program. Patients who meet the criteria for a GLP-1 are enrolled with an Omada Health care team for behavior-change support, aimed at goals such as controlled A1C, weight loss or fewer cardiovascular complications ^[1]. Evernorth pointed to a pilot with its research institute showing that members taking GLP-1s who engaged more with Omada for Prevention lost more weight than those who engaged less ^[1]. The announcement did not report how large that difference was or how many members took part ^[1].

Evernorth described the program around "cardiodiabesity" — obesity, diabetes and cardiovascular disease occurring together — which it said accounts for about $838 billion in U.S. health care costs each year ^[1].

Coverage was limited at the time. About 25% of employers covered GLP-1s for weight management, according to an Accolade survey cited by Healthcare Dive, and more than a third named cost as the barrier ^[2]. Wegovy and Zepbound were listed in limited supply by the FDA, and more than 40% of Americans had obesity, according to CDC data — a potential market Healthcare Dive estimated at close to 140 million people ^[2].

Analyst Arielle Trzcinski of Forrester said the cap is progress but questioned whether it goes far enough. "It's a step forward. Is it enough? Maybe not, but in comparison to that 40% to 50% it feels like a much more palatable number," she said ^[2].

Why it matters for patients

The guarantee is a contract between Evernorth and the employers and health plans that hire it. It does not set copays, deductibles or prior authorization rules, which are decided by each plan ^[1][2]. What it changes is the calculation a plan makes when deciding whether to keep or add GLP-1 coverage — and coverage reaches patients only if an employer signs on ^[2]. With roughly a quarter of employers covering the drugs for weight loss, experts said the guarantee could widen access ^[2].

Patients inside the program do face an extra step: enrolling in the Omada Health lifestyle program if they meet GLP-1 criteria ^[1]. The announcement does not describe what that enrollment involves, how long it lasts, or whether turning it down affects access to the medication ^[1].

What happens next

Evernorth has not disclosed how many clients have signed up, when the guarantee takes effect, or what its agreements with Novo Nordisk and Eli Lilly contain ^[2]. The savings guarantee offered as an alternative to the 15% cap is described only in general terms, with no figures released ^[1].

It also has not been reported whether the cap covers GLP-1 use for type 2 diabetes as well as for weight loss. Evernorth's announcement refers broadly to patients using the drugs to control diabetes or achieve a healthier weight, while Healthcare Dive reported that the cap applies to spending on Wegovy and Zepbound, which the FDA has approved for weight loss ^[1][2].

The announcement page was first published on March 7, 2024 and updated on Nov. 25, 2024 without new figures ^[1].