GLP-1 Coverage Decision Framework
- 1Define the covered indication: Diabetes only, obesity only, or both?
- 2Define clinical criteria: BMI threshold (30+ or 35+), comorbidity requirements
- 3Define behavioral program requirement: Require enrollment in a weight management program
- 4Define prior authorization: Clinical review before approving GLP-1 prescriptions
- 5Define step therapy: Require trial of lifestyle intervention before GLP-1
- 6Define quantity limits: Limit to one GLP-1 medication at a time
- 7Define monitoring requirements: Regular follow-up to assess response and adherence
The Long-Term Cost Commitment
GLP-1 medications must be taken indefinitely to maintain weight loss — stopping the medication results in weight regain within 12 months. This creates a long-term cost commitment that employers must plan for. A member who starts a GLP-1 medication at age 40 may take it for 25+ years — at a cost of $10,000–$15,000 per year.
The ROI Question
IQ Insight
The ROI of GLP-1 coverage is genuinely uncertain. The medications produce significant weight loss and reduce comorbidity risk — but the long-term cost savings are not yet well-established. Employers who cover GLP-1 medications should track outcomes carefully: weight loss, comorbidity improvement, and total healthcare cost changes. This data will be essential for evaluating the coverage decision over time.