The cost conundrum of GLP-1s
GLP-1 medications, including well-known brands like Wegovy and Zepbound (examples of FDA-approved drugs in this class), have quickly become the face of a weight-loss revolution, hailed for their effectiveness and sought after by employees across various industries. But with price tags averaging $12,000 per member each year, according to the National Conference of State Legislatures (NCSL), they’ve also become a budget challenge many employers can’t ignore.
The NCSL also reports that obesity affects more than 40% of U.S. adults, and these medications offer a promising path to healthier outcomes. However, that promise comes with some caveats. Most patients regain two-thirds of their weight within a year of stopping treatment, and the long-term return on investment is difficult to measure, especially in high-turnover industries where employers may never realize the savings down the line.
Meanwhile, demand is surging. As reported by the Society for Human Resource Management (SHRM), only 36% of employers currently cover GLP-1s for both weight loss and diabetes, while others are hesitant to include them in their benefits package. Employers are now caught between a rock and a rising pharmacy bill.
Fortunately, there are ways to respond with both compassion and cost control. Below are five practical strategies to help manage GLP-1 coverage in a way that supports employee health without hurting your bottom line.
1. Require a holistic weight loss program.
GLP-1s work best when combined with meaningful lifestyle changes. But too often, members start these medications without the clinical support needed to maintain results. Requiring participation in a comprehensive weight management program that includes nutrition education, exercise, and behavioral therapy can boost outcomes and help ensure members are truly committed to long-term success.
This aligns with clinical guidelines and encourages personal accountability. It also provides structure and support, reducing the risk of early drop-off or medication misuse. Many carriers and vendors may offer integrated programs to facilitate this process.
2. Set a higher BMI requirement for coverage.
Not every member prescribed GLP-1s is a candidate from a medical necessity standpoint. By setting a higher BMI threshold, such as 35+ or 30+ with a comorbidity like type 2 diabetes or hypertension, employers can focus resources on those most likely to benefit.
This approach filters out cosmetic or low-risk uses, focusing care on those with more serious health risks while helping protect the plan’s financial stability. It may affect parts of your pharmacy arrangement but usually reduces the number of eligible members.
3. Establish a lifetime limit on use.
Without clear parameters, GLP-1s can become an open-ended expense. Setting a lifetime coverage cap—such as 12 or 24 months—helps define expectations and encourages members to see the medication as a catalyst, not a crutch.
This is especially relevant given the risk of weight regain after treatment. A defined time limit creates urgency, emphasizes the importance of adopting healthy habits and allows employers to limit long-term cost exposure.
4. Increase member cost sharing.
With growing employee interest, introducing higher cost sharing through copays or coinsurance can help offset employer expenses and ensure members have a stake in the process.
This tactic not only discourages unnecessary use but also signals that these drugs are not a first-line solution. Employers may consider tiering cost sharing based on factors like clinical need or participation in weight management programs, creating incentives for more thoughtful use.
5. Offer support for cash-pay options.
Even if your plan doesn't currently cover GLP-1s or only offers limited access, you can still provide meaningful support. Resources like manufacturer copay cards and discount pharmacy pricing can help lower out-of-pocket costs for members.
This strategy allows employers to respond to rising demand without committing to high plan costs. Employers can also guide members toward lifestyle programs or lower-cost GLP-1 alternatives to keep care options open and accessible.
Chart a sustainable path with MMA Rx Solutions.
GLP-1 medications are influencing the conversation around obesity and employee health, but they’re also testing the limits of what employer plans can handle. With the right policies in place, like eligibility criteria, usage limits, and supportive programs, you can protect both your employees and your benefits plan. And even if you’re not ready to cover GLP-1s today, offering members resources to manage out-of-pocket costs can still make a meaningful impact.
For a more in-depth look, read our report about the rising demand, current clinical options, and what employers need to consider when it comes to covering GLP-1s for weight loss.
Not sure what approach is right for your population or your plan?
Our team of pharmacy consultants is here to help. Get in touch with us to schedule a consultation and learn how Rx Solutions could help you manage your pharmacy benefits with clarity, compassion, and cost control.
