One thing is certain – the surge in the popularity of GLP-1s for weight loss is something employers can’t ignore. Employer GLP-1 spending for obesity alone (excluding diabetes) nearly tripled between 2021 and 2023. Furthermore, three of the top five drugs driving the net change in cost per member per month were GLP-1 agonists.

Despite the high cost of these medications, demand has continued to increase, and employers are reluctant to reduce coverage. Between 2023 and 2024, employer coverage of GLP-1s increased by 8%. Although some employers cover GLP-1 medications only for diabetes treatment, a growing number are reconsidering this policy. Nineteen percent of organizations that cover GLP-1s only for diabetes are considering expanding coverage to include obesity.

The power of the big three pharmacy benefit managers only compounds the challenge.

“What has happened is that there has been a lot of vertical integration,” said Rick Kelly, FSA, division leader and national pharmacy practice leader for MMA. “Now you have big PBMs that have their own specialty pharmacies and mail-order pharmacies. These drugs are not just GLP-1s, but in general a lot of drugs that are very expensive. They are doing the prior authorization and if the answer is yes, many times they are doing the fulfillment.”

This consolidation has real-world consequences.

“Unfortunately, there is much more misalignment than there used to be between the PBM and the employer who is trying to provide good coverage for the right price for the right drug at the right time,” he said.

Kelly recommended five strategies for managing weight loss GLP-1 coverage:

• Require a holistic weight-loss management program, such as a third-party or PBM-managed program, to be eligible.
• Require a higher body mass index, such as a BMI of 33 or higher and at least one comorbidity.
• Set at lifetime limit, such as $10,000.
• Increase the cost share for members, such as a $300 copay.
• Help members manage price by using copay or manufacturer assistance cards.

Related: Want GLP-1 coverage? Workers willing to switch jobs for access

“Let’s say you want to cover these medications, but you want to make sure the person doesn’t have to take them forever,” Kelly said. “We are seeing that most employers who are covering weight-loss GLP-1s are making it part of a holistic weight-management or lifestyle program. A person can be changing certain things so that when they lose the weight, they don’t have to stay on the drug forever, and when they come off the drug, the weight doesn’t come back.”

There are a number of ways to structure coverage to meets the needs of workers and employers alike.

“We have a number of clients who say, `we are willing to cover this, but we are going to cover it a little bit differently,’” he said.“ It might be that they cover it for only a certain time period, like six months, or for a certain dollar amount, such as only $10,000 of coverage for one member over the course of a lifetime. Or it may be that they raise the clinical criteria, such as having the BMI threshold being 35. We also see clients who are providing education so employees can access these drugs on a cash price, which could be 30%, 40% or 50% lower.”

The answer often lies somewhere between paying for full coverage or no coverage at all.

“Yes or no, it is a big decision,” Kelly said. “But if it’s yes, there are many options, and if it’s no, there are still ways to support employees who want to use the medication.”