Advice for rural patients seeking GLP-1 access, affordability in South Dakota

More South Dakotans might have access to weight loss medication going forward, but that's only the first thing you need to know about using the popular drugs to slim down. You're listening to SDPBs in the moment. I'm Lori Walsh. Beginning in July, eligible Medicare Part D beneficiaries can pay a fixed rate of $50 per month for GLP1s. It's a pilot program and it's set to end in December 2027. But South Dakotaans, especially in rural communities, find challenges accessing medication. I talked with Jessica Strobel. She is vice president of pharmacy for Lewis. Here's our conversation. With GLP1 use becoming so popular, and rightfully so, they're a very good class of medications. They've actually been around for a long time, used for diabetes first, and then weight loss, which is obviously why they've gotten so much press lately. Everyone loves to learn about ways that they can lose weight. So, yeah, they are a very good class of medications that have become very popular, and I think that traditionally people in metro area Sioux Falls and surrounding areas have a little easier access to physicians and to specialists and other ways to see health care providers. But what really makes Lewis stand out and Sanford and Lewis relationship is our rural presence. So we're able to... give patients access to health care in communities that don't always have a large clinic presence or even a specialist on site. So we're able to bring that care right to a patient at their community pharmacy and give them access to ask questions and help them with their care, navigate coverage. So it's nice to have the availability to do that for our rural patients. So how often is the pharmacist, is the rural pharmacist the front line or the first person? person who is answering questions about medications, especially something new. You said it's been around for a while, but it might be new to you, GLP ones. Yeah, absolutely. Because pharmacists are so accessible, it's very common for patients to start with their pharmacist to ask questions first. If you think about your primary care provider, for instance, you might see them once a year, have a wellness check, or maybe go in and see them if you have something pop up, so maybe seeing them twice a year. If you're on a regular medication, you're going to see your pharmacist every month or at a minimum every three months.

We fill a three-month supply at a time for patients. But that's a lot of touch points besides people coming into the pharmacy for their over-the-counter needs or even picking up toilet paper or groceries. You have access to that pharmacist who is a trained health care provider right there. So we're very easily accessible, easy for patients to walk up and ask questions. And at Lewis Drug, we love that. We intentionally train our pharmacist to be that point of contact. to either start with answering questions or follow-up care from a physician. Yeah. What are some of the top questions your pharmacists are telling you they are getting from rural South Dakota particularly? Yeah, absolutely. I think right now one of the really common questions is how can I get a GLP1 covered or how can I get it in the least expensive way? So there are a lot of options that we have access to. Some of them include manufacturer coupons and those would be a great option for someone who's not a Medicare age patient. Now with the GLP1 Bridge program starting in July, Medicare patients also have access to lower cost, GLP1s, specifically for weight loss. Not every patient will qualify that, and our pharmacists are all trained to help a patient navigate if they qualify for that program, and that gets them access to a GLP1 for $50 a month if they qualify, which is a great price for these medications. So I think that's a very common question we get currently because of all the news that GLP1s are getting is just how can I get access? Do I qualify? for reduced cost medications, either through commercial insurance or a coupon or potentially through that Medicare bridge program if patients qualify. Let's break that down a little bit if we can. If you have a manufacturer coupon, how long does it last? That varies, and you actually don't necessarily have to walk in with a manufacturer coupon. I would say most pharmacies have access. I know for sure Lewis drugs have very easy access that when we put the prescription. in, we can just click a button to do a search to see are there any manufacturer coupons out there. So if you're walking in with one or if you aren't, you know, you still would potentially have access to those coupons, but it definitely varies per manufacturer. For the most part, some of them might do like a very discounted first month trial and then lower costs subsequently after that. Some of them might do, you know, a three to six month trial. So it does vary a lot per product. So what happens when that time? period ends because I want to go back to I mean do you need a physician to prescribe this first of all and then a trial period we understand there might be side effects and you might not continue it on but if you do want to continue it on without a discount some of these medications are a thousand dollars a month from the research that I did yes So help us parse that out. Yeah, that's a really great question because I think when we first start thinking about who should be on a GLP1, it really comes down to a lot of different factors. And so we definitely want a physician involved. A pharmacist can certainly look at the entire picture, a patient, what medications they're on, if there's going to be any interactions, maybe other disease states. But we do need that prescription to start with the provider's office. So that's definitely step one is visiting with your

your pharmacist or a prescriber to, you know, get that part initiated. Then as you start a GLP1, one of the most important pieces with this particular type of product is a titration up. So that means you have to start on a low dose and then gradually work your way up slowly. And that's super important with these medications. So that's why no matter what pharmacy you go to or what provider you're seeing, if you're going to start a GLP1, their first question should be, have you ever been on one? prior if you're just starting you have to start at a low dose and that's all about the side effects these medications do have a lot of GI side effects meaning like nausea stomach upset but if you start low and go slow is how we explain it start at a low dose and slowly work your way up it allows your system to get used to the medication so that you can tolerate them better so to answer your question yeah when you when you first get started you're likely going to be put on a very low starting dose for that titration and that sometimes where those coupons might be is on those starting doses and then gradually work your way up. If you... depending on your coverage. I mean, each coverage is different. And now that the GLP1 Bridge program came out for Medicare, it is technically only in effect for now until December 31st, 2027. So that's the same question. Medicare patients are asking is great. I have a year and a half of this. What after that? And I do hope that the Medicare system continues, or excuse me, evaluates continuation of this program because we're finding that weight loss can be such a health. way to get healthier in other ways besides the cosmetic reason of losing weight. So a lot of evaluation would go in, and I would say every person's different in terms of their coverage and how we can help them find this in the least expensive way possible. For people who are using this for obesity to treat obesity, their concern, of course, reasonably it would be reports that if I stop taking this, then I'm going to gain back, oh, the weight that I've lost. So that's... partially why you're saying that continued evaluation might be very, very important for those patients as well. Absolutely. And I'm really glad that you brought that up because one of the ways that GLPN's work is it triggers our brain to kind of feel full faster. And so I think it's really important that when you're using this type of medications to kind of learn your body and understand what that feels like to feel full because really a lot of it comes down to portion sizes and, you know, being healthy. I think a lot of people think, well, right when I stop this, I'm going to gain the weight back. That's not necessarily true if you've been implementing some lifestyle changes along with the medication while you're on it. So there's that chance to decrease your portion sizes and continue on with healthy lifestyle modifications after the medication. And some people are able to be successful. The most successful patients on GLP ones are ones that use the medication but also make other lifestyle changes. What Medicaid in South Dakota? Is it available for Medicaid patients? Currently, it is not except unless a provider fills out what we call a prior authorization form to prove other health issues. Yeah. Talk a little bit about people going off market, finding things online, compound pharmacies. I've got a cousin who's got some extra. Tell us what can go wrong with that and how to talk to your pharmacist about those sort of choices. Yes, absolutely. Once again, it's so important to have the right dose.

especially to start. And so, you know, using, especially if you're thinking my friend is using it or I'm just going to use a dose that's actually fairly dangerous because if they're on a higher dose that you've never had exposure to and you take that dose as your first dose high dose, you can actually get very sick. So, you know, the dose titration is so important and that's hard to monitor if you're just, you know, using medication from somewhere else. The compounding piece, there are reputable. compounding pharmacies that do make GLP1. So I would not do a blanket statement and say that that's necessarily a bad idea. But I think one of the issues with the GLP1 boom is just the idea of where is that source product coming from. So where is that compounding pharmacy getting that product to make it for a patient? And so it's really important to make sure you're using a reputable compounding pharmacy if you're going that way. Talk to me a little bit about... the side effects, when you would go back to your pharmacist and say this is what's happening and not just stop something without checking with the medical provider. Yeah, absolutely. It's really important to know that when you start on that low dose, those side effects should be lessened. However, they are still possible. So if you had any extreme nausea or vomiting, you would definitely want to take a break and talk to your physician or pharmacist. If you had any low blood sugars because these medications also help with with diabetes they're obviously decreasing your blood sugars so you could get blood sugars that are too low, which can cause some dizziness, sweating, heart palpitations, those kinds of things. So it's really important for a patient to know their baseline, start low and go slow like we talked about, and then if they're having side effects that are not tolerable, letting their physician and pharmacists know that. Because sometimes they are able to try a different medication in the same class that they can tolerate better, but once again, it's a matter of doing that titration. had some patients that have either missed a dose or didn't feel good, so skipped a dose or two, then they try to start back up. And if they start at the latest dose they were at, they can once again have those issues. So even just missing up to three doses, you really have to start again at that really low dose to let your system get used to it. So communication is really, really key. Absolutely. And that's one thing that I personally, obviously am biased, but I think it's extremely easy to communicate with them. pharmacist not that it's not with your provider but once again pharmacist just being so available that it's a great resource to chat with your pharmacist to get some information now some of these are shots or injectables how do the pharmacists have to walk people through the process of doing that because most people have not given themselves an injection

previously. Yes, absolutely. There are pills too, as I understand it. Yes, yep, there are pills as well. They're fairly new. The injections have been around longer. You know, yeah, really a patient could choose which one they want to start first. Some people, especially if they have an aversion to needles or giving themselves an injection, the tablet is a great start, but sometimes the tablets do have a little more of that stomach upset. So if somebody's got a sensitive stomach or, you know, prefers to try to decrease those types of side effects on the injection. might be a better choice for them. I'm sorry though I forgot what your question was. Asking your pharmacist about giving yourselves a shot. Yes, thank you. Yes. So injection technique is actually extremely important. Similar to insulins with insulins are also a peptide that are a lot older than the gLP ones. But because you're giving this into the fat tissue, we call that a subcutaneous injection. Because you're giving that into the fat tissue, you need to make sure to give it correctly so that it stays in that fat tissue. And that's what's unique about. these prescriptions is that then you just do that once a week. So you inject yourself at staying in that tissue and it's releasing in your system throughout the week. So if someone comes in with a first time, GLP1 prescription, the Lewis pharmacist will sit down and... first figure out if you know how to use it. Also make sure that you have the right equipment. What's kind of confusing about some of these GLP ones is some of them come with the needles and some of them don't. Sometimes the provider's offices kind of forget which one is which. So the pharmacists can help you figure out is everything that you need right in this box or are we going to have to send you home with some additional equipment like the needle that you'll twist on top of that pen? And then we will teach you how to do that safely and cleanly because we want to avoid infections as well. So really important to use a new needle each injection to prevent those infections. Jessica Strobel is vice president of pharmacy for Lewis. Lewis has 60 pharmacy storefronts in South Dakota, Minnesota, and Iowa. That's our conversation for today. I hope that it served you. From all of us here at SDPB, I'm Lori Walsh. Thank you for listening.