GLP-1 medications (glucagon-like peptide-1 agonists) have blown up in popularity in the last few years. The drugs have been used to treat diabetes for a couple decades now, but with the realization that they can have a significant impact on weight loss, the interest in this class of medications has shot up. A study from the University of Pennsylvania and Cedars-Sinai Medical Center found a 700% increase in use of the drugs for patients without diabetes from 2019 to 2023.
For patients who have struggled with weight loss (which includes over half of U.S. adults, according to a recent Gallup poll), these drugs can feel like a miracle cure for a problem that formerly seemed impossible. But there's a catch—and one unlikely to surprise anyone familiar with the U.S. healthcare system: the cost.
GLP-1 drugs are expensive enough to be out of reach for most people, unless they're covered by insurance. But insurance companies want to keep costs down themselves, so many won't cover them for weight loss, or require patients to jump through frustrating hoops to get approval for coverage.
In short, whether or not someone can access a GLP-1 medication generally depends on your insurance plan. If you're a small business employee whose boss uses ICHRA (Individual Coverage Health Reimbursement Arrangement) to supply health benefits, that comes with a bit of good news. You can choose the health insurance plan that's right for you. So if you know you're interested in GLP-1 drugs, you can specifically look for a plan that covers them.
Understanding GLP-1 Medications and Coverage Challenges
What Are GLP-1 Drugs?
If you're not familiar with the term GLP-1 medications, there's a decent chance you've heard them mentioned by their brand names. Some of the best known examples are Wegovy and Ozempic, but there are a few other GLP-1 options on the market, such as:
- Zepbound
- Mounjaro
- Trulicity
- Rybelsus
- Saxenda
- Victosa
- Byetta
GLP-1 drugs typically come as injections (the exception is Rybelsus, which is in pill form). Many of these are approved for the treatment of type 2 diabetes, and some are approved for weight loss. And several of them are believed to have additional off-label benefits, such as helping with heart disease and chronic kidney disease (and research is ongoing into other potential uses).
Why Are GLP-1 Medications Hard to Access?
With all the possible health concerns GLP-1 drugs can be good for, it's no surprise they've become so popular. But that popularity comes at a high cost.
The JAMA network did an analysis of how cost effective they are and found that, in spite of the health benefits they provide, they're simply not a good deal at their current price point. And if insurance companies see significant cost increases because of the popularity of a new drug, that cost gets passed along in higher premiums—which already grow at a frustrating rate year-after-year.
Insurance companies therefore either elect to exclude GLP-1 drugs from their drug formulary, or create barriers to accessing them. They may choose only to cover them for type-2 diabetes, and not weight loss or any of the other potential uses. Or they may require you to try multiple cheaper drugs first to make sure something more affordable doesn't do the trick (this is called step therapy).
For patients, these cost saving measures can feel frustrating and counterproductive. But they're in place to try and keep health insurance costs down for everyone.
How to Check if a Plan Covers GLP-1 Medications
While some patients may struggle to get GLP-1 drugs covered, you shouldn't assume the worst. KFF research found that 42% of U.S. adults under 65 could qualify for these drugs—far more than are currently using them. So if finding a plan that covers a particular GLP-1 medication is important to you, your odds are decent.
When you're in the phase of researching your health insurance options, (whether because it's open enrollment period, or you've experienced a qualifying life event), there are a couple of options for finding out how different health insurance plans handle GLP-1 coverage:
- Check the drug formulary: When reviewing and comparing your plan options on healthcare.gov or through a platform like StretchDollar, look for the drug formulary to view the list of drugs the provider covers, and which tier different types of drugs fall into. You shouldn’t have to read a long list of drugs to find the information you need, these platforms generally make it easy to search for a specific drug to see if the plan you're researching covers it.
- Contact the insurer directly: Once you've narrowed down your options, it never hurts to contact the insurance company directly to check whether the plan you're eying will cover the specific drug you have in mind, and request an estimate for the likely cost.
The Role of Prior Authorization & How It Works
For costly medications, prior authorization (PA) is a common requirement. Health insurance companies want to be really sure that you need the drug before they shell out the cash for it. This will likely delay how soon you can access the medication, but many doctors are familiar with the process and will help patients navigate it.
Here's how prior authorization typically works is:
- Step 1: Your doctor will submit a request to your health insurance company that provides an explanation for why they consider the medication to be medically necessary. If you've already tried other drugs for the same issue, they'll list all the past medications and why they didn't work for you (e.g. they didn't treat the issue, or they had untenable side effects).
- Step 2: The insurance company will review the prior authorization request to determine if it's valid. This can take up to 30 days, and sometimes they'll come back requesting more information.
- Step 3: If the PA is approved, that's that and you can access your medication (yay!). If it's denied, your doctor has the option of appealing the decision. They may try to increase the likelihood of approval on the second try by including additional documentation or further evidence of medical necessity.
Prior authorizations can be an annoyance for patients and doctors alike (the American Medical Association is pretty clear on their disapproval of the process). But for medications at the price point of GLP-1 drugs, they're a normal part of the process.
Pro tip: If you go through all the proper steps to try and get a GLP-1 medication covered and still can't get it through your insurance, there are some other options for bringing the cost of medications down. Check our post How Prescription Coverage Works to get the full list of tips.
ICHRA & Finding a Plan with GLP-1 Coverage
Small businesses that want an affordable, flexible option for providing health care benefits can use ICHRA to get the best of both worlds. The business can keep their contribution within budget and avoid hefty taxes, while giving employees the ability to choose the plan that works best for them.
If your business works with StretchDollar, the platform makes it easy for employees to identify plans that cover GLP-1 drugs. All you have to do is use our platform to check the formularies for the health plans you’re considering to see what drugs are included, then select the plan that best meets your needs. For most employees, it only takes a matter of minutes. And if your business hasn’t gotten started with StretchDollar yet, that process also only takes a few minutes—it’s easy, affordable, and helps you help your employees get better health care.
Getting the care you need in the U.S. may still have its challenges—you still have to find the right doctor and potentially deal with prior authorizations. But we can at least make the process of finding the right plan easier on you or your employees.
