Glucagon-like peptide-1 (GLP-1) drugs such as Ozempic® and Zepbound® have become increasingly popular in recent years for their effectiveness in treating type 2 diabetes and aiding in weight loss. While initially developed to manage blood sugar levels in individuals with type 2 diabetes, these medications are now commonly prescribed for weight loss purposes. This article delves into Excellus BlueCross BlueShield's (BCBS) coverage policies for Wegovy® and other GLP-1 medications, addressing concerns about cost, access, and responsible utilization.
The Rise of GLP-1 Medications and Their Impact
Medications like Ozempic® and Trulicity® have been utilized since 2006 to treat Type 2 Diabetes. These drugs, originally intended for diabetes management, have gained traction as celebrities and social media influencers promote their weight loss benefits. GLP-1 drugs function by slowing stomach emptying and reducing appetite. The first of these drugs approved specifically for weight management was Saxenda® in 2014.
The market success of GLP-1 drugs has spurred significant interest and investment in obesity medications. Many manufacturers are exploring new drugs, alternative delivery methods, and improved side effect profiles.
Challenges and Concerns
Several challenges and concerns have emerged with the increased use of GLP-1 medications:
- Skyrocketing Prices: The high cost of GLP-1 medications is a major concern. Pharmaceutical companies charge Americans significantly more than in other countries.
- Inappropriate Prescriptions: There is a risk of inappropriate prescriptions and off-label use of these medications for weight loss, potentially diverting them from patients who need them for diabetes management. More than 75% of prior authorizations submitted were not being requested for the FDA-approved indication.
- Drug Shortages: Unexpected demand and increased off-label prescribing have led to shortages of these drugs at retail pharmacies, creating access barriers for diabetic patients.
- Discontinuation Rates: Research indicates that a significant percentage of users discontinue GLP-1 medications before achieving health-improving weight loss. Excellus notes research that 58% of users discontinue before achieving health-improving weight loss.
Excellus BCBS's Approach to GLP-1 Coverage
Excellus BCBS has implemented several measures to address these challenges and ensure responsible utilization of GLP-1 medications:
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- Prior Authorization Criteria: Excellus BCBS has updated its prior authorization criteria to align with bariatric surgery standards. On January 1, 2025, BMI requirements were increased to greater than 40 mg/kg2 or greater than 35 mg/kg2 with one or more weight-related comorbidity. This adjustment aims to focus resources on members facing the highest risks of serious medical issues and life-threatening complications.
- Utilization Management Programs: To combat inappropriate prescriptions and ensure employee safety, Excellus BCBS employs utilization management programs. The prior authorization process requires healthcare providers to certify that a member is enrolled in an approved weight loss program and meets the necessary medical criteria for GLP-1 therapy.
- Clinical Pharmacist Review: Excellus BCBS's team of clinical pharmacists provides an unbiased review for each request of a GLP-1 to confirm medical necessity and safety.
- Strategic Initiatives: The increasing trend in GLP-1 therapies requires proactive engagement in strategic initiatives.
- Formulary Management: Excellus BlueCross BlueShield says GLP-1 drugs for diabetes will remain on formulary, countering reports of a blanket halt. Effective January 1, 2026, three GLP-1s for weight loss-Wegovy, Zepbound, and Saxenda-will be removed from covered lists for certain plans, though members can seek exceptions if prescribers verify criteria.
Specifics of Wegovy® Coverage
When starting Wegovy®, the dose needs to be increased slowly to reach the effective dose for weight loss. Without lower strengths of the medication available in the marketplace, the dose titration cannot be completed reliably. Using the higher strengths without dose titration could put patients at risk for side effects. Any requests for members new to therapy are not being approved to ensure those that have started treatment continue to have access.
As of January 1, 2026, Wegovy will be removed from covered lists for certain plans, but members can seek exceptions if prescribers verify criteria.
Advancements in GLP-1 Indications
In 2024, there were significant advancements with GLP-1 indications. Zepbound® received an expanded indication for the treatment of sleep apnea. As of January 2025, Ozempic® is now approved for use in patients with type 2 diabetes who also have chronic kidney disease.
The Importance of Responsible Utilization
While GLP-1 drugs possess the potential to enhance employee health, they must be utilized responsibly. By partnering with a pharmacy benefits provider such as Excellus BCBS, employers can better control costs, protect their bottom line, and ensure their workforce receives the appropriate care.
Excellus frames the shift as balancing access with affordability, pairing coverage criteria with nutrition and fitness supports through providers.
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Understanding Prior Authorization and Step Therapy
Some prescription medications require prior authorization, step therapy, or both. Prior authorization means you must get approval before you fill your prescription. If you don't get approval, the drug may not be covered. Step therapy means that you may have to try certain drugs to treat your medical condition before the insurer will cover another drug for that condition. For example, if Drug A and Drug B both treat your condition, the insurer may not cover Drug B unless you try Drug A first. If Drug A does not work for you, they will then cover Drug B. Drugs that require prior authorization or step therapy are indicated on the drug list.
The Role of Clinical Pharmacists
The Excellus BCBS team of clinical pharmacists plays a crucial role in ensuring the appropriate use of GLP-1 medications. This team provides an unbiased review for each request, confirming medical necessity and safety. Additionally, they developed a strategy for the newest drug to treat diabetes, Mounjaro®, that has led to significantly less inappropriate and off-label use for weight loss.
Addressing the Obesity Epidemic
To learn more about the complex world of weight management drugs, individuals can listen to a recent episode of The Community Check-In podcast “The Real Deal on Weight Loss Drugs.” The Senior Director of Pharmacy Strategy and Policy at Excellus BCBS, Nicole Dawley, provides valuable insights into the background of the obesity epidemic, the science behind these medications, and the importance of integrating them into a comprehensive weight management program.
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