Navigating GLP-1 drug coverage: How physicians can support patients as requirements evolve
GLP-1 drug coverage is highly variable, which makes it difficult to track what payers do — and do not — cover.
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At a Glance
- Recent GLP-1 changes include Medicare and Medicaid coverage and FDA regulations.
- GLP-1 drug coverage strategies include designating a point person and creating a reference guide.
- Engaging patients about GLP-1 can cut administrative burden and also foster patient buy-in.
GLP-1 drug coverage evolves daily amid cost pressures and emerging clinical data, making it challenging for physicians to track the latest GLP-1 prescription requirements. This guide highlights key recent changes and offers strategies for your private practice.
Recent GLP-1 drug coverage changes
- Despite a 2024 proposed rule that included Medicare and Medicaid coverage of GLP-1 medications for weight loss, CMS announced in April 2025 it would not finalize GLP-1 drug coverage for obesity.
- In April 2025, the Food and Drug Administration (FDA) published a timeline to indicate when most compounded versions of GLP-1 medications must cease production. Compounded GLP-1 medications are customized versions of commercial drugs that pharmacies typically make when an FDA-approved version is unavailable, such as during a shortage. It’s important to note that compounded medications are not FDA-approved and have not been through clinical trials. (Patients may need help transitioning from compounded GLP-1 medications to commercial products.)
- In May 2025, President Trump issued an executive order setting a 30-day deadline for drugmakers to selectively lower the cost of prescription drugs, including the cost of GLP-1 medications.
- Payer policies on GLP-1 drug coverage continue to evolve. A recent analysis found that Affordable Care Act marketplace plans rarely cover GLP-1 drugs approved solely for obesity treatment. Meanwhile, more employers are opting to cover GLP-1 drugs for obesity in their sponsored health plans.
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The bottom line? GLP-1 drug coverage is highly variable, which makes it difficult to track what payers do — and do not — cover. However, if medical practices don’t stay on top of GLP-1 prescription requirements, they risk wasting time on prior authorizations that payers won’t approve while simultaneously giving patients false hope and ultimately disappointing them. Tracking these requirements helps improve patient satisfaction, reduce costly rework, and boost medical practice revenue.
“GLP-1 drug coverage is highly variable, which makes it difficult to track what payers do — and do not — cover.”
Leveraging GLP-1 drug coverage strategies
Here are several strategies that can help you manage evolving GLP-1 prescription requirements:
- Designate a point person to monitor GLP-1 drug coverage changes. Medical coders, nurses, or care coordinators are often well-suited for this task. Partnering with your practice’s pharmaceutical representatives can also provide valuable insights.
- Create a quick reference guide for payer-specific GLP-1 prescription requirements. Keep in mind that whether insurance covers a GLP-1 may differ depending on its use for diabetes versus obesity. Payers may also have specific step therapy or body mass index (BMI) thresholds.
- Update internal resources regularly based on prior authorization approvals and denials. Ensure these resources are accessible at the point of care so physicians can have productive conversations with patients and set reasonable expectations. Note that your EHR may have built-in or integrated modules that update formularies in real time to show each GLP-1 covered by insurance versus those that are not covered.
- Have a plan to support patients who face affordability challenges. If medications aren’t covered or the out-of-pocket cost is too high, manufacturer copay cards and patient assistance programs may make them more affordable. Consider preparing a handout (e.g., “Paying for your GLP-1 medication”) that explains how patients can save money and access these medications more easily, especially if a GLP-1 is not covered by insurance for their specific situation. These resources are important, as research indicates that half of Americans assume GLP-1 medications are too expensive to even discuss with their doctor.
- Leverage manufacturer support services for GLP-1 drug coverage. Pharmaceutical companies offer resources to help with prior authorization and reimbursement. Bookmark their websites and check them frequently for downloadable forms, coverage check tools, and patient support hotlines. These can often help answer the critical question for specific patients: is their GLP-1 covered by insurance?
Engaging patients in the GLP-1 coverage process
Medical practices can also empower patients to navigate GLP-1 drug coverage complexities. For example, you could provide patients with a sample handout explaining how to contact their insurance company about GLP-1 requirements, along with their responsibilities, before they request an appointment. This proactive step decreases the administrative burden on your medical practice and also fosters patient buy-in.
Preparing your practice for ongoing GLP-1 coverage changes
As GLP-1 drug coverage changes continue to unfold, having a strategy in place to promote efficiency and avoid unnecessary rework is essential. Leveraging your EHR and creating clear internal guides for GLP-1 prescription requirements, when needed, helps medical practices stay on track as the demand for GLP-1 mediations increases.
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Want to learn more? Check out these free resources:
- Is macrodosing GLP-1s a new trend?: New data from Tebra highlights who’s microdosing, why, and the mixed reactions about this approach.
- Why patients hesitate to ask about GLP-1 medications: Many patients want to ask their doctors about GLP-1 medications — but over half are staying silent.
- Are you using eRx to manage GLP-1 prescriptions?: Learn about Tebra’s easy to use e-prescribing software.
- Current Version – Jun 18, 2025Written by: Jean LeeChanges: This article was updated to include the most relevant and up-to-date information available.
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