The increasing prevalence and high costs of GLP-1 medications are reshaping the pharmacy benefits landscape. As more patients seek these treatments for diabetes and weight loss, employers face critical decisions about sustainability and managing coverage cost-effectively.
For plan sponsors and benefits consultants navigating this evolving challenge, it is important to understand GLP-1 clinical effectiveness and utilization, as well as build a framework for GLP-1 coverage and cost considerations.
Understanding the GLP-1 Market: Rising Costs and Expanding Usage
Demand for GLP-1 products like semaglutide and tirzepatide has continued to increase, putting a burden on pharmacy benefits plans.
Notably, a recent Truveris analysis of over 1.1 million GLP-1 claims from early 2023 to early 2025 showed:
- 5x spend on GLP-1 medications indicated for weight loss (Wegovy, Zepbound, and Saxenda)
- 16% average cost increases per claim for GLP-1
Additionally, the figure below shows how Truveris’ data analysis found average GLP-1 spend increases of approximately 2x per plan sponsor.
Despite impressive clinical efficacy, real-world studies indicate high discontinuation rates—54% within one year—raising concerns about long-term adherence and sustainability of therapy benefits.
This is critical given that GLP-1s only remain effective for weight loss in the long term so long as adherence to the medication remains consistent. Without other lifestyle changes and approaches, clinical trial data demonstrates that members begin gaining weight back as soon as they end their use of the medications.
With costs for these medications continuing to increase, plans must explore strategies that help offer appropriate access to GLP-1s while managing the corresponding spend in their pharmacy budgets.
Four Strategies for Managing GLP-1 Coverage and Spend
1. Utilization Management (UM) with Prior Authorization
Effective utilization management is a strategy many plan sponsors leverage to help manage GLP-1 costs, and plans are increasingly refining their criteria, emphasizing ongoing patient progress to justify continued coverage.
Some example UM strategies that employers are using include:
- Prior Authorization – We are seeing plans beginning to take a more serious look at their prior authorization criteria, with some limiting reauthorization to patients who are achieving consistent use of GLP-1s
- Formulary – Setting member cost sharing policies for GLP-1s at different tiers
- Step therapies – Exploring other weight loss avenues that may be enough to hit specific patient milestones
2. GLP-1 Carve-Out Programs
Currently, data shows that there is a high discontinuation rate for GLP-1s and the patients receiving these therapies. Carve-out programs offer targeted, specialized support for patients using GLP-1s by improving patient access to providers with expertise in obesity and diabetes.
These programs often include:
- Personalized medical oversight and lifestyle coaching through telehealth.
- Dietitian consultations, frequent progress checks, and medication adjustments.
- Financial incentives such as partial cost reimbursements to improve patient adherence and engagement.
A successful pilot program for a US state government demonstrated significant outcomes from carving-out GLP-1s, including patient adherence improvements and cost savings of approximately $1.2 million on GLP-1s through proactive medication management.
3. Ongoing Claims Oversight
Consistent monitoring of pharmacy claims can ensure that GLP-1 medications are billed appropriately per PBM contract terms. Benefits of ongoing oversight include:
- Thorough understanding of GLP-1 utilization trends and spend over time
- Early detection of potential claim coverage errors
- Timely correction of errors that could otherwise lead to significant, unintended expenses
One Truveris client discovered over $250,000 in unintended GLP-1 expenditures mid-contract due to PBM implementation errors, illustrating the potential financial impact from a lack of transparency around pharmacy claims data.
4. GLP-1 Claims Audits
Focused GLP-1 pharmacy audits provide deeper insight into PBM accountability around utilization management controls and prior authorization criteria, highlighting potential areas of overspending and mismanagement. An audit of GLP-1 utilization and claims may provide:
- Validation of patient diagnosis and clinical necessity for GLP-1 prescriptions.
- Assessment of the consistency and appropriateness of prior authorization approvals.
- Detection of disproportionate approval rates compared to other therapeutic categories, indicating potential overprescribing.
For some plan sponsors, Truveris identified an 18% year-over-year increase in patients receiving diabetes medications driven by GLP-1 prescriptions, underlining the importance of audits for confirming appropriate medication use.
A Balanced Approach to GLP-1 Management
Navigating GLP-1 coverage complexities requires strategic, data-informed approaches to balance patient access, clinical efficacy, and financial sustainability. By leveraging robust utilization management, specialized carve-out programs, ongoing oversight, and targeted audits, plans can effectively manage GLP-1 medications to optimize both budget and health outcomes.
To learn more about these strategies, you can access our team’s in-depth discussion about GLP-1s in the recording of our May 2025 webinar here:
Truveris is a leading digital health company focused on delivering truth and clarity in pharmacy. Truveris’ proprietary technology, coupled with deep pharmacy expertise, helps to build a more efficient market that maximizes choice, accessibility, and prescription drug affordability. Our solutions provide the insight and knowledge to help people lead healthier and more productive lives.
