Helping You Navigate GLP-1 Coverage

GLP-1 medications have become an important option for treating diabetes and supporting weight management. As demand continues to grow, many employers are looking for practical ways to manage pharmacy costs while helping employees across safe, appropriate care.

A thoughtful coverage strategy can help balance affordability with long-term health outcomes. With clear clinical guidelines and the right support, you can help employees get the care they need while protecting the sustainability of your pharmacy benefit

• Long-term use can increase pharmacy costs.
• Coverage decisions today can affect future affordability.
• A thoughtful approach can help support both your employees and your benefit plan.

Five Guardrails for Responsible GLP-1 Coverage

1. Start with clear clinical criteria

Clear clinical criteria help ensure GLP-1 medications are prescribed for members who are most likely to benefit. Prior authorization supports consistent use and helps reduce unnecessary costs.

Eligibility may include:

• BMI of 40 or greater
• BMI of 35-39.9 with one or more qualifying conditions, including:
  • Metabolic syndrome
  • Hypertension
  • Dyslipidemia
  • Cardiovascular disease
  • Obstructive sleep apnea

Clinical criteria are reviewed as new evidence becomes available.

2. Pair medication with lifestyle support

Medication is one part of a successful weight management plan. Coverage may require participation in a qualified weight management program before approval.

Requirements may include:

• Enrollment in a comprehensive weight management program
• Documented participation for at least three consecutive months before approval

These programs help reinforce healthy habits that can improve long-term success.

3. Build a formulary that balances access and affordability

A well-designed formulary helps manage costs while giving members access to clinically appropriate medications.

Key strategies include:

• Lower-cost medications when clinically appropriate and preferred
• Clinical exception processes when medically necessary
• Quantity limits that support safe, appropriate [MP1] use

4. Keep primary care at the center

Primary care providers play an important role in helping members use GLP-1 medications safely and effectively.

They help:

• Determine whether treatment is appropriate
• Monitor progress and side effects
• Coordinate care with specialists when needed

Keeping primary care at the center helps ensure treatment fits each member’s overall health needs.

5. Monitor for fraud, waste, and abuse

Monitoring prescribing patterns helps identify potential fraud, waste, and abuse before they drive up costs or put member safety at risk.

Monitoring may include:

• High-volume telehealth prescribing
• Out-of-state prescribing patterns
• Utilization trends outside established clinical guidelines

Results That Matter

Managing GLP-1 medications requires the right balance of access, affordability, and clinical oversight. Early results show that evidence-based coverage strategies can help employers manage pharmacy costs while supporting members who meet established clinical criteria.

A Balanced Approach

GLP-1 medications can improve health outcomes when they’re used appropriately. As demand continues to grow, thoughtful coverage strategies can help employers balance access, affordability, and member safety.

Clear clinical guidelines, coordinated care, thoughtful formulary management and ongoing oversight can help support employees while managing pharmacy costs over time. It’s one more way a balanced approach to pharmacy benefits can strengthen the health and wellbeing of your workforce and your business here in Western New York.

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 [MP1]This more aligns with our UM policy- its not clinical but its included as part of criteria