Working in the self-funded health plan space, I am usually ahead of the curve in learning about new technology, treatments, and prescription drugs. Early in my health journey, GLP-1s and GIPs hit the market and many asked me why I didn’t attempt to go that route. The answer is personal preference and sheer stubbornness (says “I can do it all by myself” in my head); however, I also considered how expensive these drugs are for my health plan and transparently, the potential side effects were scary. In all likelihood losing weight naturally took longer, but it avoided my two main concerns.

Potential side effects of GLP-1s include nausea, vomiting, diarrhea, pancreatitis, impact to gallbladder and/or kidneys, blocked intestines, increased heart rate, suicidal thoughts, vision changes leading to potential blindness, blood clots, and greater potential for developing certain types of thyroid cancers. The most common side effects are the ones that are less severe, but still not exactly trivial ones.

As for the second concern – the finances – I will acknowledge I’m not your average health plan participant as I have been working at a health care cost containment company for over a decade.
Nevertheless, as for the cost, with a larger data set available now, the average cost among various manufacturers is still generally $1,000 or more for a month’s supply of GLP-1s in the US. Health plans that choose to cover these drugs vary to the extent to which they are covered. Meanwhile, participant out-of-pocket costs vary from plan to plan; some participants may have to cover the full cost until their deductible is met, which is a significant consideration for many.

The newest development in this area is that North Dakota became the first state to add GLP-1 and GIP drugs to the state’s benchmark plan as an essential health benefit under nutritional counseling as of January 1, 2025. The benchmark requirement reads as follows:

Coverage for dietary or nutritional screening, counseling, and therapy forobesity, diabetes-related diagnosis, or a chronic illness or condition that could bemanaged through nutritional or weight loss programs, up to 12 sessions every policy year, if prescribed by the insured's physician. This would also include coverage for the use of GLP1 and GIP drugs as therapy for prevention of diabetes and treatment of insulin resistance, metabolic syndrome or morbid obesity.

Individuals on fully insured small group health plans and individual plans that must follow the benchmark will still have to meet medical necessity requirements in order to access the GLP-1 and GIP drugs.

As a quick reminder, self-funded plans are required to select a benchmark plan. The purpose of selecting a benchmark is solely to identify which benefits are EHBs and which are not. A self-funded plan is not required to mirror the benchmark plan selected in terms of benefits and/or visit limitations – in other words, the self-funded plan does not have to cover all of the benefits that are in the benchmark and can select different visit limitations or impose visit limitations that are not in the benchmark.

Some might question why these drugs would be added to benchmark plans, while others might not find it so surprising when there are countless stories of the drugs improving individuals’ health. While my journey did not include GLP-1 drugs, I am aware of two personal success stories involving GLP-1 drugs.

The father of a coworker has had significant success with a GLP-1 drug. Diagnosed as a diabetic, he was doing everything right – eating well and exercising, but struggling to lose weight, a more challenging endeavor given some additional health issues that were all intertwined. Two years into taking a GLP-1, he has lost 160 pounds, no longer needs to be on blood pressure medication, and was recently taken off insulin. The concept of removing insulin from his daily routine was not something that anyone had imagined would be possible as he had been living with a diabetes diagnosis for over 24 years and told he would be insulin dependent for the rest of his life.

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The second success story – so far – involves one of my best friends. She knew the time was coming when her doctor was going to recommend a GLP-1 as the result of her pre-diabetic state and weight gain despite having changed her eating habits. Her doctor did diagnose her as a type 2 diabetic and she was given a GLP-1, specifically Ozempic. The success she’s had isn’t related to the medication alone – she started walking for 30 minutes on her lunch break five days a week and she’s continued to focus on making better choices when it comes to nutrition.

She attended a diabetes education class and met with a dietician regarding her overall goals. Her journey is just beginning but is going well – six months in she’s lost over 35 pounds and her blood work is showing significant improvement, including her A1c level being reduced from 7 to 5.9. Before starting Ozempic, she asked a long list of questions and did the testing to confirm that she would not be subject genetically to some of the severe side effects; however, she has experienced one of the most common side effects – constipation. She does stress to anyone that asks her about her experience, that while Ozempic has helped her, she’s put in the extra work to ensure her success by being more active and modifying her food intake. Simply put in her words, “the weight does come off, but you also have to work.”

Like any new medication, with GLP-1s we may not fully understand the long-term side effects for quite some time, but I agree with my coworker that “the cumulative cost saved in terms of treatment for other underlying issues, medications, etc. to a group really warrants consideration to cover these medications as a course of treatment.”

Only time will reveal the long-term effects and if more states will add GLP-1s to their benchmarks. The current political and legal climate surrounding pharmacy benefit managers (PBMs) is ever-changing and thus could add additional wrinkles to the mix.

At the end of the day, weight loss options, like any other health-related decisions, are very personal and must be made on a case-by-case basis. The pathway for some may not make sense for others and that’s okay. As an attorney who holds a Bachelor of Science degree, I would encourage anyone on a health journey to consider all of their options and take the path that speaks to you.

Kelly E. Dempsey is an attorney with The Phia Group, LLC. As the Vice President of Phia Group Consulting, Kelly’s specialization is an interesting mix of compliance matters impacting self-funded plans (such as issues relating to ERISA, ACA, COBRA, FMLA, MHPAEA, and MSP) and “outside-the-box thinking,” finding creative and innovative ways to help plans, brokers, and TPAs achieve their various self-funding goals. Kelly is admitted to the Bar of the State of Ohio and the United States District Court, Northern District of Ohio.