With increasing demand and higher costs, ensuring appropriate patient access is more critical than ever and 2025 will likely be key in determining the impact of GLP-1s on plan costs.

Here are the key trends we believe will determine what’s next for GLP-1s:

1. Policy in flux: The outgoing administration had proposed that the Centers for Medicare and Medicaid Services (CMS) be required to cover GLP-1s for treating obesity. While this may change with the new administration, the proposed implementation could significantly impact the commercial market, which often follows CMS’ lead.
2. Expanding scope: The U.S. Food and Drug Administration (FDA) recently approved Ozempic for reducing the risk of worsening kidney disease, kidney failure (end-stage kidney disease), and death due to cardiovascular disease in adults with Type 2 diabetes and chronic kidney disease. Additionally, Eli Lilly’s Zepbound was approved for treating moderate to severe obstructive sleep apnea in adults with obesity. Manufacturers are also pursuing expanded indications for other conditions including and non-alcoholic steatohepatitis/metabolic-associated steatohepatitis (NASH/MASH), which are in advanced trials and the FDA submission process. If approved, these expanded indications could increase treatment utilization and provide manufacturers broader access to the obesity market since many of them are often linked to comorbidities of diabetes and obesity. In many cases, this would circumvent a payer’s plan design restricting coverage for weight loss and increasing plan costs. 
3. Robust pipeline, alternative sourcing: New entrants, including some pill-based GLP-1s, could lower prices, but increased utilization may outweigh cost reductions. Meanwhile, compounding of these drugs, driven by early supply shortages, continues despite litigation by pharmaceutical manufacturers. Compounded GLP-1 alternatives could offer lower-cost alternatives but could increase demand and utilization. 
4. Emerging risks: Potential long-term impacts and risks of GLP-1s remain uncertain. Some newly apparent adverse side effects offer a cautionary note. 

Considerations when evaluating GLP-1 coverage rules

GLP-1s are undeniably effective in managing diabetes, but their high cost makes them a contentious choice for frontline treatment. Benefits advisors helping employers make plan design and coverage decisions should help them carefully evaluate two key factors: current therapy success and availability of lower-cost alternatives.

• Cost effectiveness: Lower-cost alternatives like metformin and sodium-glucose cotransporter (SGLT) inhibitors are often preferable as first-line treatments, as they provide clinically sound results at a fraction of the cost.
• Current therapy success: For patients already managing diabetes effectively on other therapies, transitioning them to a GLP-1 may not be the best decision either financially or clinically.

• Adherence challenges: Patients falling off therapy or becoming non-adherent can impact results and lead to wasted costs.
• Long-term outcomes: Weight loss results may not be sustainable over time and there may be additional costs related to future therapies.
• Financial ROI: While there’s an argument that covering diabetes management costs on the pharmacy side could reduce medical costs in the long term, conclusive evidence to support this has yet to emerge.

Thoughtful, proactive GLP-1 management strategies can save money while optimizing member access and effective use. Without proper clinical review, up to 40% of GLP-1 prescriptions are used off-label, according to RxBenefits analysis.

Here are some key approaches to consider:

• Base plan design and coverage decisions on specific goals and member needs
• Implement a comprehensive prior authorization process that is supported by diagnosis, lab results, and other documentation to ensure appropriate use 
• Leverage personalized review processes and clinical best practices for approval decisions rather than one-size-fits-all automated processes 
• Apply utilization management tools such as step therapy so that lower cost, clinically appropriate therapies are being tried first when applicable
• Promote lifestyle changes, exercise, and diet when appropriate before covering for indications such as weight loss
• Monitor emerging trends and new entrants, as well as approval of expanded indications, to stay ahead of market developments

*Assumptions: Roughly ¾ of members are adults; GLP-1 adherence is 50% mirroring current experience for obesity; additional utilization estimates limited to current non GLP-1 utilizers and individuals with the expanded label indication. 

Mark Campbell is RxBenefits' Chief Pharmacy Officer.