Express Scripts is one of the three largest pharmacy benefit managers (PBMs) in the United States, alongside OptumRx and CVS Caremark. PBMs act as intermediaries between health insurance providers and pharmacies, managing prescription drug coverage on behalf of health plans. Understanding how Express Scripts handles coverage for weight loss medications, particularly GLP-1 receptor agonists, can be complex. This article aims to provide clarity on Express Scripts' policies, recent changes, and options for members seeking coverage for these medications.
Express Scripts and GLP-1 Medications: An Overview
Glucagon-like peptide-1 receptor agonist therapies (GLP-1s) have revolutionized the management of chronic conditions like diabetes and obesity. Express Scripts recognizes this and is working to make these medications more available, accessible, and affordable.
Key Takeaways for 2024
- Express Scripts allows individual health insurance providers to opt for coverage of specific GLP-1 medications.
- For weight loss: Saxenda, Wegovy, and Zepbound may be covered.
- For Type 2 diabetes: Ozempic and Mounjaro may be covered.
- Members need to check their individual plan formularies to confirm coverage details.
- Express Scripts offers a weight management program, but access to weight loss medications through this program depends on the individual's plan.
- Medicare through OptumRx typically does not cover weight loss medications, but may cover Ozempic and Mounjaro for Type 2 diabetes.
Recent Changes and Transitions
Express Scripts® Pharmacy is transitioning home delivery prescriptions for covered, injectable GLP-1 drugs to a new specialized pharmacy. This change affects members with prescription drug benefits administered by Prime Therapeutics, where Express Scripts® Pharmacy is an in-network, home delivery pharmacy, including commercial, Medicare, and Medicaid plans. Only members with active prescriptions for a covered, injectable GLP-1 drug with Express Scripts® Pharmacy are impacted.
Prime is working with Express Scripts® Pharmacy to ensure members’ current prescriptions for covered, injectable GLP-1 drugs are transferred to EnGuide Pharmacy. Enguide Pharmacy is operated by the same company as Express Scripts® Pharmacy (Evernorth) and will offer all types of covered injectable GLP-1 prescriptions.
Notably, members are not required to use EnGuide Pharmacy to obtain covered, injectable GLP-1 drugs.
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Coverage Details for GLP-1 Medications
Coverage for GLP-1 weight management drugs, such as Saxenda, Wegovy, and Zepbound, is not a standard benefit for all members. Some Administrative Services Only (ASO) group plans may offer coverage for weight loss and/or weight management drugs as a custom benefit.
Specific Medications and Potential Coverage (2024)
- Weight Management:
- Saxenda
- Wegovy
- Zepbound
- Type 2 Diabetes:
- Ozempic
- Mounjaro
Requirements for Coverage
Coverage for these medications typically requires prior authorization to establish medical necessity. They are often placed in higher tiers within most plans, meaning they’re considered non-preferred (usually because they’re more expensive). Your plan may mandate trying step therapy medications first, typically by trialing lower-tier medications.
Express Scripts generally covers weight loss GLP-1s for individuals with a BMI of 30 or higher, or with a BMI of 27 or higher along with comorbid diagnoses such as type 2 diabetes mellitus, dyslipidemia, hypertension, obstructive sleep apnea, or cardiovascular disease. They also provide coverage for Ozempic or Mounjaro with a confirmed type 2 diabetes diagnosis. Additional requirements for coverage may include step therapy or prior participation in a weight loss program.
Checking Your Specific Plan
While Express Scripts offers coverage for these medications, specifics depend on your individual insurance plan. Many plans cover GLP-1 medications if FDA criteria are met, but others may impose restrictions such as step therapy, weight management program policies, or complete exclusions for weight loss.
Express Scripts Weight Management Care Value Program
Express Scripts offers its own weight management program to help members achieve their weight loss goals. Whether this program provides access to GLP-1 and GIP medications such as Wegovy or Zepbound depends on your individual plan, since an employer or a plan sponsor can still opt out of coverage for weight loss medications. The program's brief mentions that medication prescriptions can apply if covered under the individual’s benefit plan.
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Medicare and GLP-1 Coverage
Medicare plans generally do not include coverage for weight loss medications such as Zepbound or Wegovy through Express Scripts. Medications prescribed for weight management are likely to be denied coverage. However, certain GLP-1s may be covered for individuals with cardiovascular disease, and Medicare includes coverage for Ozempic and Mounjaro for treating type 2 diabetes. Your provider will need to submit recent lab results and chart notes supporting your diabetes diagnosis for prior authorization.
What to Do If Your GLP-1 Prescription is Denied
If your prior authorization or other request for GLP-1 coverage was denied, the first step is to check your denial letter. Common denial reasons include:
- Lifestyle modification
- No previous participation in a weight management program
- Step therapy
- Medical necessity
- Weight loss plan exclusion
A weight loss plan exclusion usually indicates your employer has chosen not to include coverage for these medications on their offered plans. It can be difficult to sway a PBM to go against the parameters of an employer’s chosen plan.
Appealing a Denial
It is possible to overturn any of these denial reasons with a well-crafted appeal. Exercising your right to appeal is highly recommended. When an appeal is submitted, the information is reviewed by a real person, specifically a doctor, who considers the unique circumstances.
Honest Care: Free Appeal Letters
Honest Care offers free appeal letters to help individuals fight insurance coverage denials. They provide a comprehensive assessment, a free appeal letter download, and the option for additional assistance with edits.
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Understanding the Appeal Process
- Insurance Appeal: A formal request to your insurance company to reconsider a decision about your claim.
- Insurance Appeal Letter: A written argument explaining why you believe the insurance company's decision should be different.
- Supporting Insurance Evidence: Documentation to back up your claim or appeal, such as medical history, diet and exercise efforts, and medication history.
Types of Supporting Evidence
- Appeal Evidence: Information provided when you disagree with your insurer's decision about a claim or coverage.
- Prior Authorization Evidence: Required when your health plan needs you to get approval before it covers certain medications or procedures.
TRICARE Coverage for GLP-1 Medications
TRICARE pharmacy benefits cover certain approved GLP-1 medications for type 2 diabetes with an approved prior authorization (i.e., Trulicity, Ozempic, Mounjaro, and Victoza). Weight loss medications (i.e., Wegovy, Zepbound, Contrave, Qsymia, and phentermine) are covered for beneficiaries with TRICARE Prime and TRICARE Select, with an approved prior authorization. As of August 31, 2025, coverage for weight loss medications will no longer be available for non-TRICARE Prime and non-TRICARE Select beneficiaries.
Weight loss medications must be:
- Prescribed by a TRICARE-authorized provider, including those at a military hospital or clinic.
- Filled at a TRICARE network pharmacy.
Express Scripts Initiatives for Affordability and Access
Express Scripts is implementing initiatives to improve the affordability and accessibility of GLP-1 medications.
Patient Assurance Program
Express Scripts will add GLP-1s for weight loss to the Patient Assurance Program, enabling savings, greater availability, and wider access for medications to treat cardiodiabesity. This program already includes insulin and non-insulin diabetes treatments and cardiovascular therapies, including GLP-1s. This expansion is made possible through collaboration with Lilly and Novo Nordisk.
EncircleRx
Express Scripts also announced updates to EncircleRx, a solution with over 9 million enrolled patients that has saved health plans $200 million since 2024.
Copay Limits
The monthly copay for GLP-1 weight loss medicines will be limited to no more than $200, potentially saving patients up to $3,600 annually. Health plan sponsors will also see a significant reduction in the net cost per prescription of GLP-1 medications.
Navigating Coverage and Saving Money
Express Scripts provides tools and resources to help members understand their coverage and find ways to save money on prescriptions.
Personalized Recommendations
After registering or logging in to the Express Scripts website, members receive personalized money-saving recommendations based on their plan, potentially saving an average of 32%.
Price a Medication Tool
The Price a Medication tool allows members to compare pricing and coverage information. This tool can be found under "Prescriptions" in the main menu after logging in. Depending on the plan, the tool can use the member's ZIP code to find nearby network pharmacies. The results will indicate whether the medication is covered and provide pricing information.
Real-Time Prescription Benefit
Before a doctor prescribes a new medication, ask if they’re connected to Real-Time Prescription Benefit. This allows them to check for the most affordable pricing and avoid coverage reviews.